Fbi bisard vial


Published on

Published in: Health & Medicine, Business
  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Fbi bisard vial

  1. 1. THE BISARD EVIDENCE BISARD’S BLOOD SAMPLE – VIAL TWO Prepared By: Ellen M. Corcella. Esq. Chief, Professional Standards Division Department of Public SafetyAssigned investigators: Sgt. Dawn Higgins and Detective Michele Rusk of the Professional Standards Division, Department of Public Safety.
  2. 2. I. INTRODUCTION. On August 6, 2010 Officer David Bisard, a sworn police officer for theIndianapolis Metropolitan Police Department (IMPD), was involved in a fatal crash whileon duty. As part of the initial crash investigation, two vials of blood were drawn fromOfficer Bisard. The vials of blood are referred to herein as Vial One and Vial Two.Officer Bisard is currently facing criminal charges as a result of this crash in The State ofIndiana v. David Bisard, Cause No. 49G051101FB002516 (hereinafter the “BisardCase”). On April 16, 2012 at 8:00a.m., Marion County Prosecutor Terry Curry informedthen IMPD Chief of Police Paul Ciesielski that one of the two blood samples drawn fromDavid Bisard, commonly referred to as “Vial Two” was not stored in a refrigerated unitfor a period of time. The prosecutor gave Ciesielski a chain of custody report for VialOne and Vial Two that demonstrated Vial Two had been in unrefrigerated storage. ChiefCiesielski notified Director of Public Safety Frank Straub. Director Straub, in turn, askedEllen Corcella, Chief of Professional Standards, to determine the circumstances thatcaused Vial Two to be held in non-refrigerated storage. As part of the investigation, allcivilian and sworn personnel involved were interviewed and all relevant documentsreviewed. a. Summary of Factual Findings The investigation found that Vial Two was maintained and preserved in theIMPD’s refrigerated storage from on or about August 6, 2010 until August 9, 2010. OnAugust 9, 2010, Vial Two was transferred to the Indiana State Department of Toxicology(“ISDOT”), where it was maintained in refrigerated storage. On August 25, 2010, VialTwo was retrieved from the ISDOT and returned to refrigerated storage in the IMPDProperty Room. On November 3, 2011, Vial Two was transferred to Property RoomAnnex J where it was stored without refrigeration until April 5, 2012. Since April 5,2012, Vial Two has been stored in refrigeration in the IMPD’s Property Room. At no timebetween August 6, 2010 and the present was the vial cap securing the blood samplewithin Vial Two ever removed. Vial Two’s seal remains intact. b. Summary of Conclusions A lack of clear policies and procedures, inadequate supervision, and a failure toproperly safeguard the Brisard evidence ultimately led to Vial Two being removed fromrefrigeration in the Property Room and transferred to a non-refrigerated location inProperty Annex J. The IMPD Property Room does not have procedures or policies formany of its primary duties and responsibilities. There are no storage or handlingprotocols for blood evidence. To the extent that policies and procedures exist, they areoutdated, poorly constructed, and do not provide adequate guidance or protocols for thedemands placed on IMPD property room personnel. Direct responsibility for theoperation of the IMPD Property Room is placed in the hands of civilian personnel. TheIMPD command staff does not provide sufficient oversight of the Property Room. Page 2 of 16
  3. 3. Neither the Property Room’s civilian personnel nor its IMPD commander were properlytrained in evidence handling or in property room management. They have not beentrained in the proper storage protocols for blood evidence. As a result of these gaps inexisting systems, policies and supervision, Vial Two was improperly transferred tounrefrigerated storage in Property Annex J. Page 3 of 16
  4. 4. II. STATEMENT OF FACTS On August 6, 2010, Lt. Stan Stephens of the Lawrence Police Department, and amember of the Fatal Accident Team (FAT), placed two vials of blood in the IMPDProperty Room under IMPD Case # DP100114281. These vials contained blood drawnfrom IMPD Officer David Bisard, who had been involved in a fatal crash earlier in theday. When Lt. Stephens turned the two blood vials into the IMPD Property Room, thevials, along with other evidence collected in the Bisard matter, were assigned controlnumber “AC 10015325” and case number “DP10114281.” It is standard procedure todraw two vials of blood. Vial Two was placed into a manila evidence envelope as is theprotocol for packaging blood vials for evidence. The standard evidence envelope used bythe property room is shown in the photograph below:Standard evidence envelope used to store blood vials. On August 9, 2010, at about 3:14 p.m., IMPD Sgt. Douglas Heustis retrievednumerous blood samples from the IMPD Property Room, including Bisards bloodsample contained in Vial Two. Vial Two was in a standard evidence envelope. Sgt.Heustis transported the blood vials to the ISDOT. Sgt. Heustis has been assigned the taskof transporting blood vials to the ISDOT since approximately 2007. According to allparties with experience in handling blood evidence related to Operating Motor VehicleWhile Intoxicated (OVWI) cases, one blood vial is routinely tested by the Indianapolis-Marion County Forensic Services Agency (FSA) for blood alcohol content (BAC). Thesecond blood vial is transported to the Indiana State Department of Toxicology (ISDOT)where it is tested for the presence of drugs. Sgt. Heustis was following the standardpractice. A property technician “closed out” Vial Two’s control number in the ACEproperty data management system, because it was understood that Vial Two would bestored at the ISDOT and not return to the IMPD Property Room as per standard practice. Page 4 of 16
  5. 5. On or about August 9, 2010, Deputy Prosecutor Denise Robinson, of the MarionCounty Prosecutor’s Office, assigned to the Bisard prosecution asked Sgt. Heustis toretrieve Vial Two from ISDOT and return it to the IMPD Property Room. On August 12,2010, Deputy Prosecutor Ed Zych wrote an email to Dr. Wu at the ISDOT, stating thatSgt. Heustis “will be stopping by to pick the sample up and return it to the IMPDProperty Room.” Sgt. Heustis was copied on the email. The existing standard practicewas that once evidence, like blood samples, were delivered to the ISDOT then thisevidence would not be returned to the IMPD property room.1 Sgt. Heustis did not informthe prosecutors that their request was contrary to standard practice. Sgt. Heustis did notinform his supervisors about the request to move Vial Two. On August 12, 2010, Judge Grant Hawkins granted a defense motion to preserveand maintain the evidence in the Bisard case. Judge Hawkins ordered that “any agencythat may have relevant and tangible evidence preserve and maintain said evidence forpossible testing and inspection by the defense at a later date.” The Order included allblood samples taken from Bisard and Bisard’s squad car in use at the time of theincident.” (State v. Bisard, Order dated August 12, 2010). On August 12, 2010, at 1:30 p.m., Sgt. Heustis sent an email to the day shiftsupervisor in IMPD’s Property Room, asking her to preserve Vial One in the refrigeratorwhen Vial One was returned from the Crime lab. Sgt. Heustis wrote “we are under courtorder to preserve all evidence in this case.” Sgt. Heustis, however, did not provide theIMPD property room with a copy of the Court Order. Sgt. Heustis did not advise hisimmediate supervisors about the Courts Preservation Order. On August 12, 2010, VialTwo was still in storage at ISDOT. Sgt. Heustis did not send the Court preservationOrder to the ISDOT or otherwise inform them of the Court Order. On August 23, 2010, DC Cunningham instructed Lieutenant Pauli Irwin topreserve the Bisard evidence after she learned about the Court Order issued by JudgeHawkins from news reports.2 DC Cunningham also instructed Lt. Irwin that she, DCCunningham, had to authorize any activity regarding the Bisard evidence. DCCunningham told investigators that Lt. Irwin, in turn, instructed Property Room ManagerTheresa Bockbrader to place a “hold”3 on the Bisard evidence. The documents reviewedconfirmed Bockbrader made an entry into ACE, and changed the responsible officer forthe Bisard evidence to DC Cunningham. A note with DC Cunningham’s order was placed1 This is because as a state agency, the ISDOT is a different jurisdiction than Marion County.2 Lieutenant Irwin was placed in charge of citizen services in August 2010, after the Bisard accident. Lt.Irwin’s areas of responsibility included the Citizen’s Service Desk, Auto Desk, Data Transcription, PropertyRoom/Annex, Latent Prints, Identification and Records, Criminal Records, Firearms and Alarm Citations.When interviewed, Lt. Irwin advised that she was unfamiliar with IMPD Property Room General Orders oroperating procedures and was not trained in evidence handling, property room management, or on how topreserve forensic evidence, such as blood evidence.3 We note that the term “hold” is a generic term used by the property room under a variety of circumstances. The term “hold” did not adequately convey that the IMPD was under a court order to preserve and maintain the evidence/property. Page 5 of 16
  6. 6. directly on the outside of the evidence envelope that contained Vial One. This note wasstill attached to Vial Ones evidence envelope when this investigation began on April 16,2012.4 On August 25, 2010, Sgt. Heustis retrieved Vial Two from ISDOT and returned itto the IMPD Property Room in new packaging -- an unmarked Styrofoam container witha rubber band around the container’s exterior.5 Initially, the Styrofoam container did nothave any exterior marking. The blood evidence vial, Vial Two, stored inside theStyrofoam container still had the original marking. Sgt. Heustis handed the unmarkedStyrofoam container to Property Room Technician Rebecca Hardin. Since there was noprotocol or standard operating procedure to re-enter a piece of evidence after it has beenclosed out of ACE, Rebecca Hardin treated the Styrofoam container and its contents as ifit was a new property item. Accordingly, Vial Two was assigned the control number “AC10016631” and case number “DP10114281 (the Bisard case number).” Hardin generateda computerized label and placed it on the top of the Styrofoam container.64 It should be noted that on August 23, 2010, Vial Two remained logged out of the IMPD propertymanagement data base and was still at the ISDOT.5 Per the practice that has been followed since the merger, blood vials transferred to ISDOT are notreturned to the IMPD property room. Instead, the ISDOT secures the blood samples or other evidence in itsfacility until the case is fully adjudicated.6 The property room did not re-assign the evidence control number pertaining to items of evidence in the Bisard case, AC#10015325. Vial Two was re-entered into the system as a “new” item – and not returned to the list of Bisard evidence. Page 6 of 16
  7. 7. The Styrofoam container was then placed inside an 81/2 by 11 standard manilamailing envelope because it was too large to fit into the standard evidence envelope usedto store blood vials. An adhesive label was secured to the outside of the envelope thatbore a bar code, the AC number, and Bisard’s case number. Officer Bisard’s name wasnot written on the manila envelope or printed out on the external label. The exterior ofthe manila envelope was also missing other important data normally found on IMPDevidence envelopes such as: the invesitgator’s/officer’s “initials,” “Time recovered,”Recovered at/From,” and an adequate description of the contents. This is the label placedon the manila envelope. Page 7 of 16
  8. 8. This is the front of the manila envelope. As explained below, the handwritten notewas added on April 16, 2012. Page 8 of 16
  9. 9. This is the back of the manila envelope as it appeared on April 16, 2012. Sgt. Heustis’ initials are not on the evidence seal. Instead the initials SLVS withthe date 9/23/2010 are on the evidence seal, which was not the date that Sgt. Heustisreturned the blood vial. The investigation determined these are the initials of Sgt. SandyStorkman. The Property Room Technician secured Vial Two in a refrigerated unit. Dueto the size of the envelope, Vial Two was not placed into the box where other blood vialswere stored. The storage box for blood vials is shown below. As a result of the following factors: a different AC number from Vial One, adifferent type and size storage container than the one normally used for blood evidence(plain manila envelope vs IMPD evidence envelope), the absence of markings to “hold”the evidence, no mention of the Court Order, and no clear markings indicating that theenvelope contained Bisard evidence – Vial Two was not adequately identified or linkedwith the Bisard case. Page 9 of 16
  10. 10. Sgt. Heustis completed a “Property Room Voucher” pertaining to Vial Two. AProperty Room Voucher is a document completed by persons requesting that property besecured in the Property Room. The data fields include a description of the property, thecase number, and whether the item should be “held” or released. Sgt. Heustis did notwrite that Judge Hawkins’ Court Order required that Vial Two be preserved andmaintained. Sgt. Heustis placed a “hold” on Vial Two. Sgt. Heustis did not write“Bisard” on the property room voucher to make it clear that the blood sample was part ofthe Bisard case. No one entered into ACE a note that an item of evidence known in thesystem as “AC# 10016631” was subject to either the Court’s preservation Order, DCCunningham’s directive, or that it was Brisard’s blood. On August 26, 2010, Beth Dale, an attorney with the Office of CorporationCounsel, emailed then Chief Ciesielski that a Court Order had been issued to preserveand maintain the Bisard evidence. Chief Ciesielski notified Deputy Chief Cunningham.This was the first time IMPD Command staff was formally notified of the Court Order. On September 2, 2010, DC Cunningham notified Sgt. Heustis by e-mail of theCourt Order. Sgt. Heustis replied to Deputy Chief Cunningham’s email that Vial Two hadbeen returned to the IMPD Property Room from ISDOT and that it was secured in therefrigerator. On November 3, 2011, Property Room day shift supervisor Stacey Kromtransferred Vial Two from the IMPD Property Room to Property Annex J. Vial Two wasamong other blood samples and forensic evidence transferred to the Annex because therefrigerators were too full to hold all of the evidence. A picture of the current PropertyRoom refrigerators is below. Page 10 of 16
  11. 11. Ms. Krom ran a report to identify evidence that had been in the refrigerator morethan one year. Ms Krom obtained the data by searching ACE by AC number. Ms. Kromran AC numbers, because the AC numbers identified the date the property was checkedinto the property room for refrigeration. Ms. Krom removed the oldest blood vials. Ms.Krom did not recognize that Vial Two was part of the Bisard Case for the followingreasons: 1) Vial Two was assigned an AC number different from the Bisard case ACnumber; 2) the manila envelope containing Vial Two was not marked with the name“Bisard,” or with a directive to “hold” the property, or with a copy of the Court Order. Ms. Krom was not required to, nor did she cross-check, the AC number with thecase number to determine whether the case was open or closed, nor did she check theJUSTIS system, or consult with the case investigator/officer to determine the status of theinvestigation or court proceedings. There are no written protocols or standard operatingprocedures to govern the transfer of refrigerated evidence into non-refrigerated storage.Ms. Krom advised that she relied on an informal and unwritten policy developed byProperty Room Manager Theresa Bockbrader7 to determine when blood evidence couldbe removed from refrigeration and transferred to the Property Room Annex. 7 Ms. Bockbrader has been the civilian manager of the Property Room since 2008. At the time ofher appointment, Bockbrader had served the IMPD for many years, but did not have experience in evidencehandling or property room management. Neither Bockbrader nor any of the employees in the PropertyRoom have received training in property room management, evidence handling and preservation.Bockbrader learned how to perform her responsibilities from the property room employees she supervised. Page 11 of 16
  12. 12. Ms. Bockbrader informed the investigators that because there were no writtenSOP’s she had to create her own solutions to solve operational issues that arose in theIMPD Property Room. Because the Property Room did not have adequate space to storeblood vials and other items requiring refrigeration, in 2009, Ms. Bockbrader developedan informal and unwritten policy regarding the storage of blood vials older than one year.Ms. Bockbrader decided that blood vials older than one year could be transferred to non-refrigerated storage in the Property Annex. Ms. Bockbrader implemented the policy afterconsulting FSA and a toxicology professor at a local university Ms. Bockbrader’sdecision, though well-intended, was not factually or scientifically consistent with theadvice she received from FSA or the university professor, nor was it reviewed orapproved by IMPD personnel in her chain of command. On April 4, 2012 at 8:00 a.m., in preparation for the State’s motion to test VialTwo and retest Vial One, DPs Hirshauer and Robinson met with Sgt. Heustis. Again, aroutine request was made by DP Robinson to Sgt. Heustis to make sure both Vials ofblood were packaged together in preparation for shipping to an independent lab in Texas,if the court allowed the requested new testing. Sgt. Heustis and DP Hirschauer went tothe property room in the city/county building and requested information on Vial Two. AChain of Custody Report was printed at 0934 hours for blood stored under the DP10114281 agency case number. DP Robinson was informed that Vial Two is in a“wharehouse.” She was immediately concerned about the integrity of Vial Two andrequested it be returned to the property room downtown. In his interview with investigators, Sgt. Heustis described events from April 4,2012: Ellen Corcella: Okay. I just want to go back to another point where he says who understood it was a very unfortunate event? Sgt. Heustis: Well I did. I know Tom Hirshauer did. Both of us understood that. Ellen Corcella: And did you convey that to anybody? Sgt. Heustis: To Denise and to Becky. Ellen Corcella: Okay. Sgt. Heustis: I mean, we obviously conveyed it to Denise that the blood had been moved, I mean she understood obviously what that meant and Ellen Corcella: That meant it was not refrigerated? Page 12 of 16
  13. 13. Sgt. Heustis: Well that it had been out at the annex, yes. At that point, okay, I was pretty sure that it had not been refrigerated in the annex. Having been in the department for a while, and having in my job you know evidence and stuff, I have been out to the annex and I never observed refrigeration out there. But I could not say with certainty that there was no refrigeration out there or whether that blood had not be refrigerated. I didn’t think it had, so at some point subsequent to that I can’t remember exactly what day it was, I spoke with I think it was Stacey Krom because she, I’d asked Becky if anybody knew about the annex out there and she said Stacey had worked out there. So I spoke with Stacey and she confirm that no, the blood at the annex is not refrigerated. But I passed that on to Denise, that confirmation, I mean I had told her already I didn’t think it was but that was the confirmation.The chain of custody report shows that Vial Two remained at Annex J, until April 5,2012, when the property room transferred Vial Two back into the refrigerator in the mainProperty Room. On April 6, 2012 Manager Bockbrader, stapled a note on Vial Two’smanila envelope directing that Vial Two should remain refrigerated. Page 13 of 16
  14. 14. On April 11, 2012, according to DP Robinson, she learned that Vial Two may havenot been maintained in a refrigeratored environment at the Annex. According to DPRobinson, this information was from officers not affiliated with the Bisard case or withany other cases specifically involving blood vials. On April 12, 2012, Vicki Coates from the Marion County Prosecutor’s Officespoke to Donna Forbes, then Chief Ciesielski’s assistant, to set up a meeting with theChief for Monday, April 16, 2012. Ms. Forbes, in turn, confirmed the time and date ofthe meeting through Microsoft Outlook. On Monday, April 16, 2012 at 0716 hrs Sgt. Heustis confirms in an email to DPRobinson, “Authority of the Property Room supervisor, there is no refrigerated storagefor any evidence at the Property Room annex at 901 N. Post Rd.” On April 16, 2012, at 8:00 a.m., Ciesielski met with Prosecutor Curry and DPDenise Robinson. Prosecutor Curry advised Ciesielski that Vial Two had been removedfrom refrigeration and transferred to Property Annex J. Prosecutor Curry providedCiesielski with the chain of custody reports for Vial One and Vial Two. The chain ofcustody report for Vial Two documented the transfer of Vial Two to the Property Annex. Page 14 of 16
  15. 15. III. CONCLUSIONS and RECOMMENDATIONS For purposes of this report, we make the observation that from day one – August6, 2010 – the IMPD was on fair notice that it was – and is –important to handle the Bisardcase, and the evidence associated with it, with meticulous care and impeccableprofessionalism. As identified herein, a series of missteps led to the placement of VialTwo in unrefrigerated storage for approximately twenty-two weeks. Despite thesemissteps, the integrity of Vial Two as the container for Bisard’s blood has not beencompromised. Bisard’s blood sample is in the original vial. The vial has never beenopened and the blood has never been tested. It is not within the purview of thisinvestigation to determine whether or not the lack of refrigeration compromised theviability of the blood sample for alcohol or other testing. The viability of this test samplemust be determined through proper scientific analysis. This investigation also revealed there are significant administrative, supervisory,and operational issues regarding IMPD’s evidence and property management. IMPDoperates five separate property/evidence facilities, many of which are in disrepair. Thereis no differentiation between the way evidence and non-evidentiary property is stored.The Property Room General Orders and procedures are out-of-date. In many cases, thereare no standard operating procedures. For example, the Property Room does not haveprotocols for storing, handling and monitoring forensic evidence (eg. blood evidence).Civilian staff is not appropriately supervised by IMPD command personnel. NeitherIMPD sworn nor civilian personnel are trained to perform their duties andresponsibilities. Sgt Heustis did not take sufficient steps to ensure the Bisard evidence wasproperly secured. Sgt. Heustis retrieved Vial Two from the ISDOT even though this wascontrary to routine practice and had never been done before. He did not seek the adviceof his superior officers as to handle the situation, nor did he inform the MCPO thatreturning Vial Two to the Property Room was inconsistent with standard operatingprocedures. Sgt. Heustis’ delay in retrieving the evidence – from August 12, 2010 toAugust 25, 2010 – contributed to the problem. Had Sgt. Heustis retrieved Vial Two on orabout August 12, 2010, Vial Two would have been in the IMPD Property Room onAugust 23, 2010, when DC Cunningham secured the Bisard evidence in compliance withthe Court’s Order. When he returned Vial Two, Sgt. Heustis did not tell Lt. Irwin, hisimmediate supervisors, or other pertinent persons about retrieving this piece of Bisardevidence from ISDOT. At no time did Sgt. Heustis inform his chain of command and/orProperty Room staff that Judge Hawkins’ had issued a Court Order to preserve andmaintain the Bisard evidence. Sgt. Heustis never advised his chain of command that VialTwo had been removed from refrigeration, transferred to Property Annex J, or returned tothe refrigeration in the Property Room. In essence, Sgt, Heustis kept his chain ofcommand in the dark regarding Vial Two. Page 15 of 16
  16. 16. Since April 16, 2012, the IMPD has undertaken a review of the IMPD PropertyRoom and its operations. The IMPD is developing new General Orders as well as Rulesand Regulations concerning evidence handling and property management. Additionalrecommendations regarding property room operations and management will beforthcoming in a separate report. Page 16 of 16