Review board releases report on Ingram-Lopez and Alvarado in-custody deaths, Tucson

Over 30 contributing death factors. Over 50 recommendations to first responders.

Review board releases report on Ingram-Lopez and Alvarado in-custody deaths, Tucson
Tucson leaders hosted a news conference June 24 to talk about the in-custody death of Carlos Adrian Ingram-Lopez.

TUCSON, Ariz. (KOLD News 13) - A review board has released its reports on the in-custody deaths of two Tucson men earlier this year.

In April 2020, Carlos Adrian Ingram-Lopez died while in custody of the Tucson Police Department.

You can read more about Ingram-Lopez’s case HERE, but the Pima County Office of the Medical Examiner said the cause of death was “sudden cardiac arrest in the setting of acute cocaine intoxication and physical restraint with cardiac left ventricular hypertrophy as a significant contributing condition.”

Damien Alvarado died while in TPD custody in March 2020.

The Pima County Office of the Medical Examiner said Alvarado’s cause of death was “sudden cardiac arrest in the setting of acute methamphetamine intoxication and restraint.” Alvarado’s toxicology report showed positive tests for amphetamine, methamphetamine and THC.

But these statements were not enough for many people, especially with the topic of police-brutality being such a huge talker around the country.

In response, a review board consisting of leaders and thinkers within law enforcement agencies was summoned to review, analyze, conclude and make recommendations on the changes that need to be made to law enforcement agencies and their protocols.

You can read the Sentinel Event Review Board’s full report below.

Assisting the review board were two experts on the field: John Hollway, Executive Director of the Quattrone Center for the Fair Administration of Justice from the University of Pennsylvania Carey Law School, and Michael Scott, Clinical Professor and Director of the Center for Problem-Oriented Policing at the Watts College of Public Service and Community Solutions at Arizona State University.

Both experts guided the SERB review board in a process to identify the acts, omissions, management, institutional, social and environmental conditions that resulted in the deaths of Ingram-Lopez and Alvarado, while in TPD custody.

The SERB team identified more than 30 contributing factors and conditions leading to the two deaths; and over 50 recommendations were made by the SERB Review Board on modification to policies, procedures, supervision and the environment in which first responders make decisions leading up to tragic events.

The report says no single-factor contributed to the deaths of the two individuals.

“Each death resulted from a cascade of contributing factors, some caused by individuals and others caused by the environment in which those individuals were acting, which increased the likelihood of these undesired outcomes.”


Contributing Factors: Approaching the scene

1. Inability of a 911 call-taker to effectively communicate with caller due to language barrier.

2. A lack of gathering information from the caller during the 911-call and lack of transmitting information to responding officers.

3. The failure of the call-taker to identify the [Ingram-Lopez] call as a behavioral crisis rather than a law enforcement emergency.

4. The dispatch’s framing of the call, including information shared with responding officers and communication of outstanding domestic violence arrest warrant, contributed to the officers' approach [to the Ingram-Lopez call] as one of arresting a criminal, rather than helping a community member in the midst of a drug- induced psychosis.

5. The failure of responding officers to pre-plan response to incident and establish clear incident command and responsibilities.

Contributing Factors: Officer engagement and placement of restraints

1. Officer mindset focused on apprehension of suspect rather than de-escalation of situation and protection of all participants.

2. Drug use and intoxicated state of decedent.

3. Community member witnesses were present on the scene and engaged with one suspect, impacting TPD officers' actions in the Alvarado case.

4. Behavior of officers approaching the respective scenes.

5. Officer decisions to go “hands on” rather than use deescalation technique in the Ingram-Lopez case.

6. Officers' use of profanity.

7. Failure to fully acknowledge the rapid onset of cardiac arrest or asphyxia in restrained individuals who have taken stimulants.

Contributing Factors: Handling a suspect in-restraints

1. Use of TARP on Mr. Alvarado. TARP is a close proximity restraint system used on individuals that strains an individual’s ability to breathe, which has been banned in other departments across the country.

2. Medical impact of physical restraint on medically compromised persons.

3. Keeping Mr. Ingram-Lopez restrained in reverse position on his stomach and failing to place decedent in a recovery position.

4. Failure to provide decedent water upon request in the Ingram-Lopez case.

5. Use of spit sock.

6. Inappropriate use of blankets in the Ingram-Lopez case.

7. Lack of clarity on primacy of TFD vs. TPD for individuals who are in police custody but have elevated risk factors for negative health outcomes.

8. In each of the cases there was a break of 60-90 seconds in CPR chest compression while restraints were removed from individuals and the individuals were transitioned to TFD emergency medical care.

Contributing Factors: Post-incidental managerial and investigatory practices

1. Lack of structured training for TPD OPS investigative practices.

2. OPS was led by a relatively new lieutenant (~1 year) reporting directly to an assistant chief, who did not emphasize standardized training on specific techniques useful in the OPS context, especially for officers whose prior roles at TPD were not investigative roles.

3. The COVID-19 pandemic complicated normal operating

4. Failure to show video to superior officers at the April ELT meeting. Officer concern over public backlash should have indicated the severity of the incident and merited showing the video to superior officers.

5. Failure of ELT to proactively insist upon viewing the BWC in cases of in-custody death, regardless of whether it was offered to them.

6. OPS lieutenant permitted officers involved in Ingram-Lopez case to return to duty three days after the incident without a need for additional training, reinforcing to the ELT the lieutenant’s view that the incident was not extraordinary and that the decision not to show the video to ELT was appropriate.

7. Failure to invite sergeant assigned to investigation to the April ELT meeting.

8. Failure of sergeant to explicitly question lieutenant’s handling of the video and investigation.

9. Multiple management points within OPS were staffed by relative newcomers to the internal affairs functions.

10. Pause in completion of administrative investigation while awaiting resolution of criminal investigation.

11. Press releases biased in favor of defending police actions.

Contributing Factors: Structural issues

1. Indicators of systemic racism, cultural disregard or ignorance and an indifference to Latino life were perceived by at least some members of the SERB.

2. Dehumanization of suspects and perceived indifference of officers.

3. Potentially insufficient and/or ineffective education and training for officers in key areas.


The board concluded that there is now obligation to learn from these tragedies to try and prevent similar outcomes in the future. The board describes the new obligation as forward-looking-accountability.

The members of the SERB team state that TPD, PSCD and TFD should find ways to ensure that their employees are properly trained on how to handle cases, in areas such as:

- Responding to and triaging calls that have both mental/behavioral health and law enforcement aspects.

- De-escalation.

- Officer and medic responses to individuals experiencing respiratory distress.

- Safe and appropriate methods of restraint.

- Evaluating the medical condition of an individual in restraints, and

- Excited delirium.


*Specific recommendations for each one of the Contributing Factors mentioned in the report, and recommended by the SERB Review Board, can be found by searching through the 78-page document.

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