The Aug. 2 report recommended that officers James Pike, Baron Osterman and Guy Abrams be "severely disciplined."
The 33 blows that officers delivered with their PR-24s -- better known as "nightsticks" -- were inconsistent with Jones' level of resistance, according to investigators with the Citizen Complaint Authority (CCA). Jones' flailing arms could be construed as the natural human impulse for self-defense, the report says (see "Death in Custody ," issue of Dec. 10-16, 2003).
That is especially true in the case of Jones, whose obesity put him at higher risk for asphyxiation, the report noted. A person whose air supply is restricted naturally struggles to get into a position to breathe.
Positional asphyxiation, also known as sudden death syndrome, has concerned law enforcement agencies for a decade now, CCA Director Wendell France told the CCA board. In addition, the Cincinnati officers who engaged Jones vaguely recalled having received training about it a year earlier.
Even so, seven officers "failed to follow correct procedure as outlined in Cincinnati Police Department Training Bulletin 2003/1," the report says. "The officers failed to act for approximately 40 seconds as Mr.
For this, the CCA sustained allegations of improper procedure and recommended that all seven officers receive more training on positional asphyxiation.
The CCA also found that the police department's internal investigation didn't follow normal protocol.
Hamilton County Chief Deputy Coroner Robert Pfalzgraf, who examined Jones' body the day he died, told CCA that Cincinnati police hadn't consulted him before giving their executive summary to Prosecutor Mike Allen. Consultation with the pathologist who performed the autopsy and prepared the death certificate was "normal national investigative protocol," usually done before police submit their investigation to the prosecutor, the report says.
Allen ruled March 22 that none of the officers violated state criminal statutes.
Coroner Carl Parrott Jr., ruled Jones' death a homicide, though "homicide" only denotes death at the hands of another without indicating intent or fault.
Pfalzgraf told CCA investigators that, in his medical opinion, placing Jones on his stomach led directly to his death.
"The most significant factor was the restraint, and the fact that he was face down and obese," Pfalzgraf said. "And, which led to not getting enough oxygen, which slowed his heart down. That's probably, you know, putting him face down on his belly was the straw that broke the camel's back."
The report found other faults in the way police handled Jones' erratic behavior.
Officers should have waited to engage Jones until an officer trained to deal with mental health issues arrived.
"The officers' initial approach to Mr. Jones was inappropriate because they failed to exhaust all their options and properly keep their distance," the report says.
Then, while Jones lay prone on the ground, a newly arrived officer fired pepper spray in Jones' face after verifying that he'd already been Maced. The CCA ruled the second chemical irritant deployment "unwarranted and unreasonable."
There were some discrepancies between officer testimony and the CCA's analyses. For instance, an analysis of the police car's video didn't support Osterman's claim that Jones seemed to be reaching for the officer's gun as the man kneeled on the ground before falling onto his stomach.
The CCA based the conclusions on interviews with 17 public safety officials, 19 civilians and Pfalzgraf, as well as analyses of police and fire radio transmissions, 911 calls and two police car videos.
The CCA board voted Aug. 2 to pass the CCA investigators' findings and recommendations on to City Manager Valerie Lemmie, who oversees the police department.
All The News That Fits: Leads, entrails and tales we couldn't get to.