New Autopsy Report Renews Concerns about Arizona’s Execution Protocol

An autop­sy of Richard Djerf, who was exe­cut­ed in Arizona in October 2025, has renewed con­cerns about the state’s lethal injec­tion exe­cu­tion pro­to­col and the state’s efforts to address long­stand­ing exe­cu­tion-relat­ed con­cerns. Mr. Djerf was con­vict­ed for the September 1993 mur­ders of four mem­bers of the Luna fam­i­ly in Phoenix. The autop­sy, con­duct­ed by Pinal County Chief Medical Examiner Dr. John Hu, estab­lished for the first time that med­ical per­son­nel encoun­tered sig­nif­i­cant dif­fi­cul­ty insert­ing intra­venous lines nec­es­sary for lethal injec­tion, mark­ing the lat­est chap­ter in a trou­bled his­to­ry of IV-relat­ed com­pli­ca­tions in Arizona executions.

The autop­sy revealed sev­en nee­dle punc­ture marks on Mr. Djerf’s arms — four on the left and three on the right — indi­cat­ing mul­ti­ple failed attempts to estab­lish an IV line. Examiners found that the nee­dle tip in the left arm ​“does not appear to be in the vein” and con­tained ​“a small amount of clear flu­id present” in the sub­cu­ta­neous tis­sue beneath the skin, sug­gest­ing failed placement. 

These find­ings under­score a recur­ring prob­lem in Arizona’s lethal injec­tion exe­cu­tion process. Between 2010 and 2022, med­ical teams failed to secure IV lines in the arms of 11 of 16 pris­on­ers and resort­ed to inser­tion in the femoral artery, locat­ed near the groin. According to Dale Baich, a for­mer fed­er­al cap­i­tal defend­er, at least six of those exe­cu­tions required mul­ti­ple attempts to place the femoral line itself.

Three exe­cu­tions in 2022 exem­pli­fy some of these dif­fi­cul­ties. Media wit­ness­es report­ed the exe­cu­tion team in the case of Clarence Dixon spent 25 min­utes attempt­ing to insert IVs in Mr. Dixon’s arms before per­form­ing what appeared to be an unau­tho­rized ​“cut­down” pro­ce­dure to place the IV in his groin. Legal experts, includ­ing law pro­fes­sor Deborah Denno of Fordham University, char­ac­ter­ized these pro­longed attempts as those of an ​“unqual­i­fied exe­cu­tion­er” and evi­dence of ​“des­per­a­tion.” Frank Atwood​’s exe­cu­tion, just a month lat­er, pre­sent­ed a sim­i­lar issue: after ini­tial fail­ures to estab­lish an IV line, wit­ness­es report­ed that Mr. Atwood him­self instruct­ed the exe­cu­tion team to insert the IV line in his hand. Months after the exe­cu­tions of Mr. Dixon and Mr. Atwood, Arizona moved to car­ry out the exe­cu­tion of Murray Hooper. Difficulties with IV inser­tion even­tu­al­ly also required a femoral artery place­ment, with Mr. Hooper report­ed­ly ask­ing wit­ness­es, ​“Can you believe this?” as the process unfolded.

Another sig­nif­i­cant con­cern with lethal injec­tion has been the poten­tial for acute pul­monary ede­ma, the accu­mu­la­tion of flu­id in the lungs that experts char­ac­ter­ize as caus­ing sen­sa­tions akin to drown­ing. Prior to Aaron Gunches’ exe­cu­tion in 2025, University of Richmond law pro­fes­sor Corinna Barrett Lain drew atten­tion to a 2020 study find­ing that 84% of 58 exe­cu­tions using a sin­gle-drug pen­to­bar­bi­tal pro­to­col showed acute pul­monary ede­ma. However, autop­sies of both Mr. Gunches and Mr. Djerf revealed no sig­nif­i­cant pul­monary ede­ma. The find­ings prompt­ed Mr. Baich to observe that ​“either ADCRR was unusu­al­ly for­tu­nate, or it changed its exe­cu­tion prac­tices dur­ing last year’s executions.”

Following the botched exe­cu­tions in 2022, Governor Katie Hobbs ordered an inde­pen­dent review of the state’s exe­cu­tion process ​“to review and pro­vide trans­paren­cy into the [Arizona Department of Correction, Rehabilitation & Reentry’s (ADCRR)] lethal injec­tion drug and gas cham­ber chem­i­cal pro­cure­ment process, exe­cu­tion pro­to­cols, and staffing con­sid­er­a­tions.” In November 2024, almost two years after Gov. Hobbs’ order, state Attorney General Kris Mayes announced her office would resume seek­ing exe­cu­tion war­rants. ADCRR indi­cat­ed in let­ters to Gov. Hobbs that depart­ment offi­cials had imple­ment­ed changes to the pro­to­col and would be pre­pared to resume exe­cu­tions, includ­ing expand­ing the med­ical and IV team from two to four per­son­nel, includ­ing two med­ical doc­tors and one phle­botomist; increas­ing train­ing require­ments from one ses­sion to quar­ter­ly train­ing ses­sions with live IV catheter inser­tion prac­tice; and insti­tut­ing a pre-exe­cu­tion health assess­ments of prisoners.

Despite these mod­i­fi­ca­tions, sig­nif­i­cant ques­tions about the trans­paren­cy of these gov­ern­ment deci­sions and actions per­sist. Arizona pre­cludes the pub­lic from infor­ma­tion about exe­cu­tion­er qual­i­fi­ca­tions and lethal injec­tion drug sourc­ing, cit­ing statu­to­ry pro­tec­tions. Investigative report­ing has raised con­cerns about the chain of cus­tody, stor­age con­di­tions, and poten­tial via­bil­i­ty of pen­to­bar­bi­tal sup­plies obtained in October 2020 and housed in unmarked containers.

Retired Federal Magistrate Judge David Duncan, whom Gov. Hobbs appoint­ed to con­duct an inde­pen­dent review of the state’s exe­cu­tion pro­to­col, raised con­cerns about doc­u­men­ta­tion, trans­paren­cy, and the chain of com­mand for lethal injec­tion drugs. Gov. Hobbs abrupt­ly ter­mi­nat­ed Judge Duncan’s review in November 2024 after he had begun his inves­ti­ga­tion, stat­ing that his inquiries had gone ​“far afield” of her request and that an inter­nal ADCRR report had addressed her con­cerns. Judge Duncan protest­ed his dis­missal and ques­tioned whether he would have rec­om­mend­ed aban­don­ing lethal injec­tion in favor of alternative methods.

Arizona is set to car­ry out its next exe­cu­tion on May 20, 2026, with the sched­uled exe­cu­tion of Leroy McGill. As of January 21, 2026, 108 pris­on­ers remain on Arizona’s death row.