Ishmail Thompson lived nearly 30 years without any major health problems before he set foot inside the Dauphin County Prison last year, according to his medical records.
But 21 minutes after corrections officers pepper sprayed him in the face, secured a spit hood over his head and forcefully locked him into a restraint chair, he was found unresponsive, not breathing and in cardiac arrest.
His brain was so deprived of oxygen following the altercation that he fell into a coma from which he never recovered. He died a few days later, on July 29, 2021, according to medical records.
Dauphin County Coroner Graham Hetrick said Thompson’s death was due to “complications from cardiac dysrhythmia” and ruled the manner of death as “undetermined.”
County commissioners, meanwhile, put out a news release that simply said Thompson died from a “medical episode” while in a cell.
The release further noted there had been “no evidence of a physical assault” prior to his death, even though jail guards had filled out multiple forms documenting their use of force, which also was recorded on their body cameras.
The fact that guards had used pepper spray, a spit hood and restraint chair in the minutes before Thompson fell unconscious weren’t made public until last month, nearly a year later, when PennLive requested “extraordinary occurrence” reports as part of a project looking at deaths connected to the prison.
PennLive also obtained Thompson’s autopsy report, which was shared along with the use of force reports with Dr. Roger Mitchell, chair of the pathology department at Howard University School of Medicine and former chief medical examiner for Washington D.C.
His thoughts on the case were clear: This was a homicide.
“He was alive prior to the altercation, and the altercation is what we call a significant intervening factor,” he said. “When an altercation in general is a significant intervening factor, that becomes a death at the hands of another, which is a homicide.”
It does not matter whether the use of force by corrections officers led to Thompson going into cardiac arrest, Mitchell said, or if he was asphyxiated by his breathing being restricted through the multiple uses of force. It only matters that their actions triggered the medical event that caused his death, he said.
“Whether they find the officers were criminally or civilly responsible for the death, that should not impact the fact that the altercation led to the death,” Mitchell said. Dauphin County District Attorney Fran Chardo has cleared corrections officers of criminal wrongdoing in the case.
County officials refused to answer questions about the death or their news release, citing that Thompson’s family filed a notice of intent to sue in December. Hetrick also did not respond to requests for comments about his ruling.
The death of Thompson, whose obituary described him as a die-hard Lakers fan and entrepreneur who loved being with his family, was one of the at least 16 deaths connected to the jail since 2019.
Lower Swatara Township police arrested Thompson around 10 a.m. on July 23, 2021. They said he was wandering around naked outside a hotel and had punched an employee. Officers originally charged him with assault and criminal trespass.
Earlier that day, Thompson left his home in Delaware. It’s unclear why he ended up in Dauphin County. He told doctors later he wasn’t sure how he got to Harrisburg.
Thompson clearly was having some sort of mental health crisis, as police brought him into the jail around 3 p.m. for an involuntary mental-health commitment.
Using jails as mental health facilities is a recipe for disaster, according to Michele Deitch, director of the Prison and Jail Innovation Lab at the University of Texas, an academic program that promotes safer treatment of incarcerated people. That’s because staff are generally not properly equipped or trained to deal with these issues and often mental health problems can make it difficult for people to follow a jail’s stringent rules.
Officers often use force more frequently on people with mental health issues, which Deitch said is particularly problematic because many of those people are more medically vulnerable.
Compounding this, she said that many of the responses corrections officers use for disruptive behavior, such as restraining the person or placing them in solitary confinement, can exacerbate mental health issues and lead to more problems.
But jails have become de facto mental health facilities.
Before the jail would accept Thompson, jail staff asked police to take him to a hospital to be evaluated and medically cleared.
Hospital staff wrote that Thompson initially refused to cooperate and was acting strangely but eventually became alert and spoke with doctors.
A series of medical tests at UPMC Harrisburg, including head and spine imaging, showed no significant issues. A blood test showed only a minute amount of THC, the psychotropic ingredient in marijuana. No other drugs were detected.
The only issue noted on Thompson’s medical record from the visit was slightly low potassium levels, which doctors treated.
Thompson was then released from the hospital, arraigned at the jail, and placed under medical observation at 8:09 p.m. Several hours passed as he waited to be fully processed into the jail.
Medical staff noted that Thompson was acting “anxious, disorderly and inappropriate” around 12:30 a.m., as he continued to wait. Nothing was recorded or documented indicating he was so disruptive that staff used force on him.
All that changed in the next hour when he was moved from the jail’s judicial center to booking.
At 1:28 a.m., Thompson refused to put on his jail smock, ran into the shower area of the jail and began “wetting himself down,” according to use of force records.
Three officers attempted to restrain Thompson. One sprayed Thompson with oleoresin capsicum spray — commonly referred to as pepper spray — and used a “leg sweep” to try to get him on the floor. Thompson resisted and punched that officer in the face, according to the officer’s reports.
Several more officers responded to help restrain Thompson. They shackled him, placed him on the floor on his abdomen and pulled a mesh spit hood over his head because officers said he was spitting at them after being pepper sprayed.
But it can be dangerous to place a spit hood over someone’s head after they have been doused with pepper spray, according to Shannon Pieper, a spokesperson for Lexipol – a company that provides policies used by more than 5,000 police and local government agencies in 35 states.
Pepper spray can reduce a person’s ability to breathe, and while a spit hood is considered breathable, it can become clogged with increased mucus and saliva from pepper spray, she said. The spit hood also can prevent the pepper spray from dissipating and further restrict the person’s breathing.
A spit hood manufactured by Humane Restraint comes with a warning that “improper use can lead to asphyxiation, suffocation or drowning in one’s own fluids.”
It’s unclear what brand of hood Dauphin County used on Thompson because they would not answer questions. But Chardo provided a photo of a new, and different spit hood that guards started using earlier this year.
Lexipol’s model use of force manual, which is considered a “national best practice,” states that a spit hood should not be used on someone who has been pepper sprayed until they are fully decontaminated.
Pieper said this is done to protect the safety of the person in custody and prevent officers from escalating the use of force by misinterpreting why the person is spitting.
“For many individuals, spitting is a natural reaction to the application of [pepper] spray,” she said. “Decontamination can bring a stop to the spitting, eliminating the need for the spit hood.”
The county’s use of force manual at the time of Thompson’s death stated that pepper spray “causes mucus membranes to swell, producing an almost immediate closing of the eyes, uncontrollable coughing, gagging and gasping for breath” with effects lasting “up to 45 minutes.”
That same manual, however, provided no guidance for the use of spit hoods.
The county updated its use of force policy in January, as part of a top-to-bottom review of jail practices, according to Chardo.
The new policy provides guidance on the use of spit hoods, Chardo said, but county commissioners refused to elaborate and denied PennLive’s request to review a copy of the updated manual.
Minutes after officers pepper sprayed Thompson, the officer he punched was seen by medical staff for his injury. Three minutes later, another officer went to the medical unit to have pepper spray cleaned off his face.
During this time, officers attempted to put Thompson into a restraint chair but they said he resisted. At 1:40 a.m., Thompson was successfully forced into the chair and his hands, feet and chest were strapped down.
Two minutes later, he was seen by a nurse, who quickly cleared him to be placed in a cell in the chair, without removing his spit hood.
The county’s use of force manual at that time stated that such checks only need to determine if the person sustained any injuries while being placed in the chair and ensure the straps are not cutting off blood circulation.
Seven minutes later, at 1:49 a.m., a corrections officer noticed Thompson having trouble breathing and requested help. That’s when Thompson stopped breathing and lost consciousness, according to officers’ reports.
Jail employees are supposed to provide an opportunity to clean off the pepper spray “after control has been established and/or resistance has ceased,” according to the jail’s use-of-force manual at the time.
That never happened for Thompson.
A nurse wrote that when she arrived at Thompson’s cell after the medical emergency, he was “found in [the] restraint chair with the spit guard in place.”
Staff removed him from the chair, placed a defibrillator on him — but no shock was advised — and said they began CPR until emergency medical staff arrived and took Thompson to the hospital.
Over the next several days, doctors determined Thompson had become brain dead. Thompson’s family declined to comment for this story.
Thompson, 29, is not the first person to die under these conditions.
Alfie Herrera, 39, died after corrections officers in Lehigh County pepper sprayed him, put a spit hood over his head and placed him in a restraint chair in 2013. His family lost a subsequent civil suit against the county.
A 2020 report from The Marshall Project found at least 20 deaths connected to the use of restraint chairs in the United States in recent years.
South Australia banned the use of spit hoods in 2021 following the death of an indigenous man five years earlier. It is now a crime there to use spit hoods.
In Dauphin County, 21-year-old Ty’Rique Riley became unresponsive and stopped breathing while corrections officers attempted to put him in a restraint chair in June 2019. He died a few days later in the hospital. Coroner Hetrick said he died of brain inflammation and that the condition existed prior to his arrest. His family has sued the county.
District Attorney Chardo said his decision not to prosecute officers in Thompson’s death is based solely on whether he believes the officers acted in a criminal manner, not whether corrections officers did the right thing by using force.
“I think based on the training they had, on the policies they had and the way [Thompson] was acting at the time – the threat that he posed – it was not a criminally negligent homicide,” he said.
Chardo described Thompson’s death as tragic but not foreseeable.
Chardo acknowledged it was likely the use of force by officers that triggered the medical emergency that led to Thompson’s death.
Despite this, the county did not report Thompson’s death to the state and federal government, as required by law, because they claim he was not “in-custody” when he died.
That’s because while Thompson was unconscious in the hospital, Chardo’s office had Thompson’s cash bail condition eliminated to allow his family to see him before he died without corrections officers being there.
Federal and state law requires all deaths in county jails be reported to both the Bureau of Justice Assistance and the state Department of Corrections.
Thompson’s death was reported to neither.
“The lengths the facility went to in distancing themselves from this incident shows they cared less about a human being in their care and custody than they did about covering their asses,” said Claire Shubik-Richards, executive director of the Pennsylvania Prison Society. “It also indicates that they believed the people in their care and custody were so disenfranchised that they could get away with hiding a homicide.”
Chardo, whose office is not responsible for reporting in-custody deaths, said he felt Thompson’s death should have been reported and said he would work with county officials to try to get better reporting in the future.
He also bristled when shown a copy of the county’s news release last year that said his office investigated and found “no evidence of physical assault” prior to Thompson’s death.
“I would not have phrased it precisely that way,” he said.
The deaths of 15 people are connected to their incarceration in Dauphin County Prison between the beginning of 2019 and the end of 2021. The county only reported eight to the state as required.
County officials have signaled their desire to improve conditions at the prison. They hired former state Secretary of Corrections John Wetzel late last year to help fix problems and update policies and procedures.
“You have to be transparent,” Wetzel said during a July 28 Dauphin County Prison Board meeting. “You have to confront uncomfortable stuff.”
But questions about full transparency remain.
County officials denied most of PennLive’s requests for details on jail policies, access into the jail, and answers about retention policies for video surveillance footage and whether they kept the body camera footage from Thompson’s incident.
At PennLive’s request, the county did voluntarily release the use of force reports for Thompson and more than a dozen other people who died at the jail.
John Hargreaves, director of volunteers for the Pennsylvania Prison Society and Dauphin County resident, said he has seen significant improvements in use of force at the jail, as well as access that oversight groups like the Prison Society have had to the jail in recent months.
Since 2019, guards have reduced the use of restraint chairs by 32 percent, and pepper spray by nearly 15 percent, according to DOC statistics. The state does not track the use of spit hoods.
“The prison has become much more transparent in the last 18 months,” Hargreaves said.
Despite those statistical gains, Dauphin County is still among the top jails across the state for pepper spray use against incarcerated people.
Only nine other counties across Pennsylvania reported more frequent use than Dauphin County, and Dauphin County’s use of restraint chairs remains higher than the state average, according to DOC statistics.
“It’s only by shining a light on what happens inside the jail that we can help keep people inside safe,” said Deitch of the Prison and Jail Innovation Lab at the University of Texas. “In any setting where an institution has total control over the lives and well-being of people inside, there are risks involved.”
Below is the press release from Dauphin County giving news of Thompson’s death, and a copy of the use of force report filed by corrections officers describing what happened.
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