CITY OF PORTLAND
OFFICE Of THE

CITY AUDITOR

Office of City Auditor LaVonne Griffin-Valade

11m

1221 S.W. 4th Avenue, Room 140, Portland, Oregon 97204
phone: (503) 823-4078
web: www.portlandoregon.gov/auditor

BNSURING OPEN AND
ACCOUNTABLB GOVBRNMENT

MEMORANDUM

Date: July 22, 2010
To:

Mayor Sam Adams
Commissioner Randy Leonard
Commissioner Dan Saltzman
Commissioner Nick Fish
Commissioner Amanda Fritz

From: City Auditor LaVonne Griffin-Valade
Re:

Accept the report of the OIR Group's review of the closed investigations of the death in
custody of James Chasse, Jr.

As authorized in City Code 3.21, the Portland City Auditor and the Auditor's Independent
Police Review (IPR) division issued an RFP in October 2009 for an independent
expert/consultant to review the closed investigations relating to the death in police custody of
James Chasse, Jr. Proposals from six qualified vendors were evaluated by a selection
committee made up of two community members from the Citizen Review Committee, the City
Auditor, and two staff members from IPR. aIR Group's proposal was selected in that process,
and a contract was executed in January 2010.
Since mid January, consultants from the aIR Group met with Portland Police Bureau
members, IPR staff, cOlmnunity members, and others significant to the investigations, many of
whom were interviewed on multiple occasions. All investigatory materials and pertinent
tactical, training, and procedural documents were provided to the expeli consultants from the
aIR Group for their review and analysis.
The final report from the aIR Group on the review of the closed investigations of the incustody death of James Chasse, Jr. is attached. The report outlines a number of findings and
makes 27 recommendations based on their review of the Chasse investigations. The aIR
Group will present those findings and recommendations before City Council at 6:00 p.m.,
Wednesday, July 28 in Council Chambers.

Report to the City of Portland
Concerning the In-Custody Death
of James Chasse

Prepared by
Michael Gennaco, Robert Miller & Julie Ruhlin
OIR Group
323-890-5425

July 2010

OIR

GROUP

OIR

GROUP

CITY OF PORTLAND
OFFICE OF THE

CITY AUDITOR

•

Office of City Auditor LaVonne Griffin-Valade
Auditor’s Independent Police Review Division
Mary-Beth Baptista, Director

ENSURING OPEN AND
ACCOUNTABLE GOVERNMENT

1221 S.W. 4th Avenue, Room 140, Portland, Oregon 97204
web: www.portlandoregon.gov/auditor/ipr

July 22, 2010

To:

Mayor Sam Adams
Commissioner Randy Leonard
Commissioner Dan Saltzman
Commissioner Nick Fish
Commissioner Amanda Fritz

From: City Auditor LaVonne Griffin-Valade
Mary-Beth Baptista, IPR Director
Re:

OIR Group – Report concerning the in-custody death of James Chasse

The in-custody death of James Chasse on September 17, 2006 was a significant event in
this community. Concerns regarding the actions of the Portland Police Bureau and the
other public and private entities involved with Mr. Chasse during the two hours between
his initial encounter with law enforcement and his death in the back seat of a patrol vehicle
have lingered for almost four years. For example, local officials, community members, and
police officers have asked how this deadly force incident might have been prevented, and
they have questioned why the internal investigations took three years to complete.
The City Auditor has had the authority to hire outside experts to review closed Police
Bureau investigations of officer-involved shootings and in-custody deaths since 2002, and
the Auditor’s Independent Police Review division has overseen and published five of those
expert examinations since that time. However, the attached review from the OIR Group is
the first such report focusing on a single incident. It is also the first time a review was
conducted prior to completion of civil litigation.
We broke with past practice in our approach to the expert review of Mr. Chasse’s death for
several reasons. Local officials and a broad spectrum of community members raised a
number of procedural and policy issues, and over the course of the three-year investigation
period, many called for greater transparency and responsiveness from the Police Bureau.
The immediacy of the public’s interest in this case was clear and compelling, prompting us
to move forward with an expert review once the investigations closed in September 2009.
We also did not delay the expert review pending civil litigation because we have been
convinced that to be meaningful and relevant to City officials, the Police Bureau, and the

public, such reviews should be timely, occurring as close to the event and investigations as
possible. The primary purpose of these reviews is to determine what improvements should
be made in existing police practices and tactical decision-making, as well as in the
mechanisms used for police oversight. Waiting until civil litigation ends before conducting
expert reviews undermines that goal, largely because civil law suits in these matters tend to
go on for many years. Further, OIR group’s report recommends that outside reviews of
critical incidents should not be dictated by the pace of any resulting litigation. We concur,
and in the future, we plan to launch expert reviews of all such cases at the close of
investigations, contingent upon the availability of financial resources.
The report from OIR Group sheds considerable light on the Police Bureau’s investigations
of the events surrounding Mr. Chasse’s death and makes substantive recommendations for
change. We appreciate the thorough analysis and clarity in presenting the results of this
important review, and we thank the OIR Group team members for their professionalism
throughout and for their thoughtful attention to the unique qualities of this jurisdiction.

CONTENTS
Introduction

1

I.

3

Summary of Findings

II. Scope of Review

7

III. Summary of Facts

8

IV. Homicide Detectives’ Investigation
A. Detectives Activities
B. Organization and Pace of Investigation
C. Delay of Involved Officer Interviews
D. Personnel Responding to Scene

13
13
15
16
20

V. Internal Affairs Division Investigation
A. Timeline of the Investigation
B. Quality of the Investigation
C. Delays and Lessons Learned

22
24
28

22

VI. Training Division Analysis and Recommendations

32

VII. Unit Commander’s Review

34

VIII. Use of Force Review Board
A. Chasse Review Board
B. Use of Force Review Board Structural Issues
IX. The Bureau’s Corrective Actions
A. Policies
1. Emergency Medical Custody Transport Directive
2. Revised Use of Force Policy
3. Foot Pursuit Policy
4. Mobile Crisis Unit
B. Training
1. CIT Training
2. Videos, Bulletins, and In-Service Training
C. Foot Pursuit Data Collection and Tracking

36
36
38
40
41
41
42
42
43
44
44
44
45

X. Supervisory Issues

45

XI. The Decision to Carry Mr. Chasse to the Patrol Vehicle

46

XII. Personnel Issues
A. PPB Hiring of Involved Deputy
B. Assignment/Status of Officers during Pending Investigation

48
48
48

XIII. Transit Police Division Challenges

49

XIV. Transparency

52

Investigative Review Timeline

55

List of OIR Group’s Recommendations

56

Responses to the Report

61

Introduction
Nearly four years ago, James Phillip Chasse died tragically in the City of Portland as a
result of his arrest and detention by Transit Division officers. Since that time, community
members have struggled to understand how what started as a routine contact with police officers
could have ended with such tragic consequences. While the public was understandably roiled by
the initial accounts of the incident and the Medical Examiner’s finding that the cause of death
was blunt force trauma, the Portland Police Bureau promptly began an investigation to try to
learn how and why this incident happened.
That those questions remained incompletely answered for so long only served to fuel the
public’s concern and growing frustration about the incident. The media correctly recognized that
this incident struck a nerve and impacted the psyche of a community with a tradition for its
caring and humanistic sensitivity in dealing with the mentally ill. Unfortunately, despite that
history and in light of recent economic challenges impacting negatively on the public mental
health safety net, this incident has taught that, more recently, too often it is a police officer, not a
social worker, who is the first responder to a person in crisis. As we see below, as this case
unfolded, the Bureau soon recognized that its officers did not have the tools and training to deal
optimally with such individuals. It is hoped that the Bureau-mandated training provided to each
officer in response to this incident may have changed perspectives so that chase and apprehend is
not necessarily the first response in the future in dealing with individuals like Mr. Chasse.
In reviewing the account of the incident presented here and our critiques and
recommendations, we provide the reader a few preliminary observations. First, it must be
recognized that the Portland Police Bureau of 2010 is not the Portland Police Bureau of 2006.
As we discuss more fully in our Report, critical systemic reform, much arising out of this
incident, has improved the investigative processes, policies, training, and review that we critique
below. Second, unlike most comparable police agencies, PPB has a long regarded tradition of
opening up its vault of materials and personnel to exacting outside review. The Bureau’s
orientation and acceptance of recommendations from those independent voices has left the
Bureau head and shoulders above most comparable agencies with regard to the way in which it
investigates critical incidents and most importantly, the way in which it reviews and learns from
1

them. There still remain too many police agencies that perform, at best, a cursory investigation
of a critical incident and whose review consists of the Chief placing a “duly noted” stamp on that
investigation and finding a place for the report in a file cabinet. PPB is not one of them.
Despite the Bureau’s comparatively excellent processes for investigating and reviewing
critical incidents, we found much room for continued improvement of those processes. Missed
investigative issues, review issues, policy issues, training issues, systemic issues, and the
inordinate delay in the completion of the investigative process are all catalogued here. The
recommendations we offer are intended for the Bureau to consider additional ways in which it
can continue to improve on all of those processes.
Some might suggest that our review is simply Monday-morning quarterbacking and that
we were not present in real time to face the challenges of the involved officers, the investigators,
and the Bureau’s reviewers and executives in dealing with this unprecedented case. Our
response is to not only accept that point but embrace it; the most important thing a police agency
can do in response to a tragic outcome is to perform an exacting investigation and review so that
the organization and its officers can be better trained and equipped to deal with tomorrow’s
circumstances. We are hopeful that our subsequent independent review will provide another
opportunity for introspection for the Bureau with respect to this incident, so that it can continue
to refine and improve the way in which it investigates and reviews critical incidents. To the
degree the PPB investigation and review left issues unidentified and unaddressed, our review is
intended to fill in those gaps so that the Bureau can consider them at this time.
To those in the public, we offer this Report as an independent account of the Chasse
incident and how the Bureau investigated and reviewed the matter. To the degree we point out
weaknesses and deficiencies in those efforts, it is balanced by the Bureau’s self-examination and
proactive measures. Perhaps the best testament to the Bureau and the City leaders’ openness was
the cooperation that allowed us to effectively do our work and their willingness to have each of
our findings and recommendations presented to their public.

2

I. Summary of Findings
On September 17, 2006, a Portland Police Bureau officer and a Multnomah County
Sheriff’s deputy contacted James Phillip Chasse, who ran from them as they pursued him on foot
for a short distance. The officer forced him to the ground, where the deputy and a Portland
Police Bureau sergeant joined the officer in a struggle to handcuff Mr. Chasse. Mr. Chasse died
later that evening as a result of this encounter.
The Bureau responded to this incident by initiating a Homicide investigation and
submitting the evidence to the District Attorney for presentation to the Grand Jury. Though we
offer several recommendations for improved documentation and timeliness of interviews, we
found the work done by Detectives to be thorough, exacting and relatively swift. Our key
recommendations regarding the Homicide investigation include:

•

Taking the necessary steps to interview involved officers contemporaneously with the
incident;

•

Conducting face-to-face interviews with civilian witnesses soon after the incident;

•

Addressing the need to have private ambulance personnel cooperate with in-custody
death investigations;

•

Documenting the transport of officers from the scene;

•

Adding Internal Affairs personnel to the roster of those expected to respond to the scene
of the incident.
The Internal Affairs Division interviews were thorough and fair but the investigation

suffered significant delays because of the length of time Homicide took to complete its
investigative book and forward to IAD, staffing shortages at IAD, and Multnomah County’s
decision to not let its employees be interviewed by investigators until after they had been
deposed in the civil case. Moreover, the IAD investigation – which received an unusual amount
of attention and intervention from Bureau executives – had significant gaps in information
gathering, including insufficient attention to the jail videotape; the lack of attention to alleged
3

on-scene conduct by Bureau personnel, including allegations of inaccurate information about Mr.
Chasse being conveyed to a civilian; the failure to interview all of the officers who assisted in
restraining and carrying Mr. Chasse; the failure to sufficiently follow up on the delay in taking
Mr. Chasse into the jail while the involved officers completed paperwork; and the failure to
attempt to question jail personnel about any statements made by the involved officers.
We offer several recommendations intended to help the Bureau avoid similar delays in
future cases and ensure a robust IAD investigation. Among these:

•

Creating internal policy to ensure timely completion of the Detectives’ notebook and
timely handoff of materials to IAD;

•

Drafting internal policies recognizing the importance of the IAD function and ensuring
that essential resources not be diverted away from the unit;

•

Enlisting the assistance of its Commissioner and/or City Council when encountering
investigative roadblocks created by outside government agencies;

•

When a witness may be unavailable for a lengthy period of time, considering whether the
investigation should proceed apace with the information already available;

•

Having IAD work more closely with the Detectives on scene to ensure a more thorough
collection of facts and exploring of issues at the criminal phase of the investigation;

•

Encouraging IAD to explore and develop any potential supervisory issues as part of its
critical incident review;

•

Forging an agreement with other agencies that ongoing civil litigation should not be a
reason for refusing to provide PPB access to their personnel.
Our report comments favorably on the well-considered training analysis that was

prepared relating to this incident. We did note several issues that were not explored in the
analysis, namely the involved supervisor’s failure to hand off command of the scene to an
uninvolved supervisor, the potentially harmful manner in which Mr. Chasse was carried to the
patrol car, and the lack of a breathing guard in the patrol car when officers were attempting to
4

render first aid. We also found that when new information was brought forward as a result of the
enhanced videotape, a revised training analysis should have been completed. With regard to
those missed training issues we recommended that the Bureau revisit them and consider whether:

•

A directive should be devised requiring that any supervisor directly involved in a
significant use of force relinquish his or her role as incident commander once an
uninvolved supervisor responds;

•

Policy and training should be revised regarding the transport and carrying of subjects in
maximum restraints;

•

When new evidence is to be considered, the Training Division should update and revise
its analysis based on that new information.
With regard to the Use of Force Review Board, we found that the Board provides an

objective mechanism through which issues of accountability, training, systems review,
supervision, and equipment can be effectively assessed. That being said, we offered the
following recommendations designed to improve the Board’s quality of review:

•

A reconsideration of the advisability of encouraging involved officers to appear before
the Board and when they do appear, limiting the scope of presentation to facts;

•

Notifying all Board members of the final outcomes of cases in which they participate.
Throughout our review, we heard repeatedly that Transit Division had a particular way of

doing business that set it apart from the rest of the Bureau and gave license to tactics not
supported by Training or condoned in other divisions. We also heard that this was a direct
response to community expectations and Transit Division’s mission to eliminate drug sales and
nuisance crimes from on and around the transit system. We believe the Bureau should:

•

Take action to evaluate these differences, to the extent they still exist;

•

Ensure future timely and complete cooperation of non-Bureau officers in Bureau incustody death investigations;
5

•

Work with the other agencies whose officers work in the Transit Division to agree upon a
common core of accepted tactics and training and provide that training to all Transit
officers.
The Bureau already has instituted a number of remedial measures to address some of the

training and tactical issues and policy deficiencies this case presented. It did so quickly and on
its own initiative. While the Report offers several suggestions for improvement of the Bureau’s
new policies and training initiatives, we applaud the Bureau’s efforts to learn from the Chasse
case and use it as a vehicle for change. Most notable among these are:

•

Mandatory Crisis Intervention Team training for all officers;

•

Training officers to consider the severity of the crime before initiating a foot pursuit;

•

Requiring officers to give paramedics complete information before deciding how to
transport subjects;

•

Roll-call videos on foot pursuits, Taser use, and other subjects.

We also examined the Bureau’s decision to hire the involved deputy during the pendency of
the in custody death investigation and recommended that it consider developing a policy of not
hiring lateral candidates while they are under investigation.
Finally, we examined the role of IPR in the review of the Chasse incident and noted the
evolution of the City Auditor’s oversight entity. Consistent with that evolution, we
recommended that:

•

IPR continue in its dialogue with the Bureau to develop a protocol in which it regularly
responds to critical incidents;

•

Consider establishing a more visible and public presence during the pendency of a critical
incident investigation.

6

II. Scope of Review
In October, 2009, the Portland City Auditor and the Auditor’s Independent Police Review
Division (“IPR”) caused the City of Portland to issue an RFP for an independent
expert/consultant to review the internal investigations relating to Mr. Chasse’s death, to analyze
the Bureau’s relevant training and policies, and to evaluate the Bureau’s administrative response.
OIR Group replied and was eventually selected to perform this review and analysis. We are
pleased to report that we received complete access to PPB reports, documents, photographic and
video evidence, and forensic evidence pertaining to the Chasse in-custody death. We reviewed
current and previous PPB policies and procedures as well as training documents and videos. We
interviewed Detectives and Internal Affairs investigators, training staff, command staff, PPB
executives and former executives, government attorneys, and IPR staff. We also met with
community groups and members of the Citizen Review Committee, and spoke with citizen
members of the Use of Force Review Board. Throughout our review, we received complete
cooperation from PPB members and all other stakeholders who responded candidly to our
questions. As called for in the RFP, we also reviewed reports and recommendations from the
Police Assessment Resource Center (“PARC”) that have been prepared periodically since 2003.
This report intends to discuss the facts surrounding the police encounter with Mr. Chasse
only to provide the necessary background and framework for our discussion of the Bureau’s
investigative response, relevant policy issues, and corrective actions. We were not engaged nor
would it be appropriate for us to provide an after-the-fact opinion on the correctness of the
outcome of the Bureau’s administrative decision making process. Rather, we focus on how the
Bureau investigated this in-custody death and what it learned for purposes of accountability and
systemic reform. Throughout, we make recommendations intended to improve the Bureau’s
future performance and response to such critical incidents.

7

III. Summary of the Facts
On September 17, 2006, a Transit Police Division team consisting of one Portland Police
Bureau officer and one Multnomah County Sheriff’s Office deputy1 were working a routine
patrol assignment when they stopped to assist a PPB sergeant during his contact with an
individual near NW 18th and NW Everett in the City of Portland. During that contact the officer
noticed another individual, later identified as Mr. Chasse, standing nearby. His initial impression
was that Mr. Chasse was transient and, because of the way he moved, likely intoxicated. The
officer stated that Mr. Chasse appeared to notice them and then quickly walked away, leading
him to suspect that he had an outstanding warrant and wanted to avoid police contact. He told
the sergeant and deputy about his observation and stated that they should try to stop him if they
were later provided the opportunity.
The opportunity to stop Mr. Chasse presented itself within minutes. After they cleared
the original call, the sergeant drove off while the officer/deputy team left in a separate patrol car.
The officer and deputy again saw Mr. Chasse near the 1300 block of NW Everett. At this time,
the officer observed Mr. Chasse with his back to him in a manner that suggested to the officer
that Mr. Chasse was either urinating or possibly injecting drugs into his hand. The deputy
described Mr. Chasse as hunched over, as though he might be trying to discard drugs. The
officer stated he was concerned about the public’s safety, Mr. Chasse’s welfare with regards to
the possible intoxication, and the likelihood that Mr. Chasse had an outstanding warrant. The
deputy reiterated these same concerns, but also added that he thought Mr. Chasse might need to
talk to Project Respond, the mobile mental health crisis response team for Multnomah County.
The officer and deputy decided to contact Mr. Chasse, so the deputy stopped the car and they
exited the vehicle and approached Mr. Chasse on foot. The deputy called out to Mr. Chasse,
who turned his head, looked at the officers with a terrified expression, and then ran. The officers
immediately pursued.

1

This deputy is now a PPB officer, after having been hired by the Bureau shortly after this
incident. For ease, we will continue to refer to him as a deputy throughout this report.
8

Within approximately 30-40 feet, the PPB officer caught up to Mr. Chasse. Accounts
vary on the manner in which Mr. Chasse was forced to the ground. The officer described using
the “knock down technique,” developed by Training as a preferable alternative to grabbing
someone to take them to the ground and end a foot pursuit, and shoved Mr. Chasse in the back,
causing him to stumble and fall forward. Other witnesses report seeing the officer wrap Mr.
Chasse up in a bear hug type of tackle, or according to one witness, take him down with a flying
tackle. Two civilian witnesses described seeing three policemen chasing the subject then all
falling to the ground together with the subject. The end result was the same – Mr. Chasse fell
hard to the pavement. The officer also fell to the ground, either as a result of the tackle or
because he lost his balance as he knocked Mr. Chasse down. In statements made to paramedics
at the scene, the officer steadfastly denied that he had landed on Mr. Chasse when he fell. In his
later Homicide and Internal Affairs Division (IAD) interviews, he allowed it was possible that
some part of his body had landed on Mr. Chasse. In a video recorded later that evening in the
jail holding cell area, the deputy appears to demonstrate in the officer’s presence a takedown
similar to a bear hug tackle. The forensic evidence suggests that the officer did fall on top of Mr.
Chasse, and the City’s position in the litigation was that Mr. Chasse’s most serious injuries were
the result of the officer landing on him at the end of the foot pursuit.
The involved sergeant observed the officer and deputy chasing Mr. Chasse, and stopped
and exited his vehicle to assist. The sergeant was in front of the pursuit at the time and intended
to intercept Mr. Chasse. Instead, he watched as Mr. Chasse and the officer went to the ground,
and then got involved in the struggle to secure Mr. Chasse. Ultimately, the officers restrained
Mr. Chasse with handcuffs and a hobble device that secured his legs and attached to his wrists
behind his back.
There are conflicting reports and observations about the force the officers used in their
efforts to restrain Mr. Chasse. According to the reports of the officer, deputy, and sergeant, the
officer used an arm bar to try to control one of Mr. Chasse’s arms, punched him in the face with
a closed fist, and pushed and pulled at his shoulders. The deputy attempted to control Mr.
Chasse’s legs, struck Mr. Chasse in the back with a closed fist, drove his knuckle into his back
rib area as a pain compliance technique, and used a Taser in the drive-stun mode on Mr.
9

Chasse’s thigh or buttocks area, which seemed to the officers to have no effect. The sergeant
also reported using force during the struggle: he kneeled on Mr. Chasse’s shoulders and/or back
in an attempt to pin him, attempted to control one arm with a wrist lock, kicked him in the chest
and then put the sole of his boot against Mr. Chasse’s jaw (in response to Mr. Chasse biting him
on the calf).
Civilian witness accounts vary on the type and amount of force used. One witness
described a “chaotic struggle” in which Mr. Chasse twisted and turned and displayed a great deal
of energy while officers, surprisingly, could not restrain him. At the same time, it appeared to
that witness as if the kicks and blows she saw the officers deliver were unnecessary, as it
appeared to her the Taser effectively brought Mr. Chasse under control by rendering him
unconscious. Another civilian witness described seeing officers punch and kick the subject in
the head. Another witness observed officers press their knees on Mr. Chasse’s shoulders, neck
and legs. Other witnesses also described the intense struggle to restrain Mr. Chasse. One saw
him attempt to bite an officer. Another heard an officer say, “Don’t bite me.”
Once Mr. Chasse was restrained, it appeared to the officers that he had a brief period of
unconsciousness. They called for paramedics to respond. Two paramedics from the private
ambulance company American Medical Response (“AMR”) arrived first, followed by two
Portland Fire paramedics. The involved PPB sergeant took the lead in communicating with
paramedics. He informed them Mr. Chasse had run from and fought with police and had been
momentarily unconscious, but did not provide any details of the struggle, including that the Taser
had been used. When interviewed, the AMR paramedic with whom the sergeant communicated
said the officers were cooperative and she felt she had all the information she needed to assess
Mr. Chasse. Though Mr. Chasse was conscious but not responsive to any of their questions and
struggled with the paramedics, his vital signs – pulse, respirations, blood pressure – were all
within normal limits. The paramedics additionally administered a blood glucose test, which also
was normal. One AMR paramedic advised the sergeant Mr. Chasse appeared to be fine and
could be transported to jail, but also offered to transport him to the hospital. She asked the
officer to sign an AMR Information Form, which is a form given to patients who decline to be

10

transported by Emergency Medical Services (“EMS”). While the officer thought the request was
unusual, he agreed to sign the form for Mr. Chasse.
The PPB officer and sergeant, along with one or two other officers, then carried Mr.
Chasse to the patrol car, approximately 30-40 feet away. The vehicle had not been moved since
the deputy stopped it to contact Mr. Chasse initially. Mr. Chasse remained in maximum
restraints and was carried face down, with one officer at each armpit. Mr. Chasse struggled
while being carried, screaming and pulling against the restraints and attempting to bite the
transporting officers. The officers believed Mr. Chasse’s aggressive, erratic behavior indicated
he was on drugs. They did not consider that he might be mentally ill. The officer and deputy
secured him in their patrol vehicle and transported him to the Multnomah County Detention
Center (“MCDC”) without further incident.
One civilian witness mentioned that after she watched Mr. Chasse being carried away, a
PPB officer asked if she wanted to know what had happened, then volunteered that the arrestee
had 14 narcotics convictions and the officers had found cocaine on him. We now know this
alleged account by a PPB officer of Mr. Chasse’s criminal history was not true. No other
civilian witnesses reported hearing this or any similar comments, though some were troubled by
what they perceived as laughing or joking by officers and paramedics.
When they arrived at the jail with Mr. Chasse, the officer and deputy parked in a lot
across the street to complete the Custody Report and Property Receipt before driving to the jail’s
sally port. At the jail, the officer and deputy, with the assistance of three other MCSO deputies,
placed a spit hood on Mr. Chasse to prevent him from biting and carried him into a cell, where
the handcuffs and hobble restraint, but not the spit hood, were removed. In the cell, Mr. Chasse
appeared to again lose consciousness, though he continued to breathe. Two nurses assigned to
MCDC looked at Mr. Chasse through the window in the cell door, then advised the officer they
would not clear him for admittance to the jail and that he needed to be transported to the hospital
for evaluation. At least one of the nurses saw Mr. Chasse experience what appeared to be a brief
seizure and overheard that he had briefly lost consciousness. The nurses did not advise the
officer to call for an ambulance. The officers and deputies then carried Mr. Chasse – in
handcuffs and leg chains, but not hobbled or in maximum restraints – back to the patrol car.
11

The officer visually monitored Mr. Chasse on the drive toward Portland Adventist
Hospital. On the freeway, he appeared to stop breathing, so the deputy exited the freeway and
requested an ambulance. He stopped the car at NE 33rd and NE Clackamas Street and pulled Mr.
Chasse out from the backseat. They removed the spit hood, the deputy swept Mr. Chasse’s
mouth for obstructions to his airway, and the officer began chest compressions. The deputy
looked for a breathing mask so that he could administer breaths, but could not find one. A
resident from a nearby house came out with an Automated External Defibrillator (AED), which
is used to administer an electric shock to someone in cardiac arrest. He attached it to Mr.
Chasse, but the machine’s computer advised not to administer the shock. Portland Fire and
AMR (different paramedics) responded and AMR transported Mr. Chasse to the hospital, where
he was pronounced dead a short time later. From the time officers first contacted Mr. Chasse at
NW 13th and NW Everett, the incident lasted just under two hours.
The State of Oregon Medical Examiner conducted an autopsy the next day and
determined the cause of Mr. Chasse’s death to be blunt force chest injuries.2 Specifically, Mr.
Chasse had 27 fractures of 14 ribs. Some of those fractures were displaced and three penetrated
the left lung, causing intense hemorrhaging. During her interview with IAD, the Medical
Examiner elaborated on Mr. Chasse’s injuries. In her opinion, ten of the rib fractures were
caused by chest compressions administered in attempts to resuscitate Mr. Chasse. None of these
fractures contributed to Mr. Chasse’s death. According to the Medical Examiner, the best way to
explain the other 17 fractures, all along the back, is that they occurred with a single broad-based
application of force, such as someone or something falling on top of Mr. Chasse, and not from
individual blows. She based this conclusion on the location of the fractures and the fact that
there was no evidence of corresponding external injuries (contusions or lacerations) that she
would expect to see if the ribs had been fractured by individual blows. She also noted that Mr.
Chasse’s bones were very fragile and brittle, more like those of a 60- or 70-year-old woman than
a 45-year-old man, concluding it would have been easier to break Mr. Chasse’s bones than one
would expect.

2

Our observations are based on the Medical Examiner’s report and her interview with IAD.
12

The Medical Examiner at first questioned the reports that Mr. Chasse’s vital signs were
within normal range, because such normal readings are inconsistent with the injuries she found
to Mr. Chasse’s body. When IAD investigators showed her documentation from AMR verifying
the various readings, she opined that the readings, while within normal limits for most people,
may not have been normal for Mr. Chasse. She also opined that the ribs may have been fractured
but not displaced at the time of the initial blunt force trauma, so that the lung was not punctured
at the time Mr. Chasse was examined by the paramedics at NW 13th and NW Everett, but that the
way in which Mr. Chasse was moved about – carried to the car and into and out of the jail –
exacerbated the rib fractures and caused the internal injuries.
Later, during the course of the investigation, Detectives learned that a PPB officer had
accompanied a mental health worker from Project Respond to visit Mr. Chasse at his apartment
two days before his death. That visit had ended abruptly when Mr. Chasse fled from his
apartment building and from the officer and the mental health worker.
IV. Homicide Detectives’ Investigation

A. Detectives Activities
The PPB Detectives responsible for investigating the in-custody death arrived at the NE
Clackamas Street scene within about 30 minutes of the time Mr. Chasse was pronounced dead.
The process that resulted in the alert to Homicide Detectives actually began prior to Mr. Chasse’s
death. While Mr. Chasse was being removed by paramedics from the NE Clackamas Street
scene to the hospital, a patrol sergeant on scene at NE Clackamas Street apparently concluded
that his death could be imminent and contacted the precinct which, in turn contacted the sergeant
handling the Homicide team. While en route and soon after arriving at the NE Clackamas Street
scene, the Homicide sergeant summoned an investigative team that included six Homicide
Detectives and three Detectives from the East County Major Crimes Team as well as crime scene
technicians and photographers to document and measure the scene and to collect evidence at the

13

direction of the Detectives. He also called the District Attorney’s Office and requested a Deputy
DA on scene.3
The Detectives’ reports indicate that when they arrived on scene, they immediately
ensured that the involved officers had been separated and began directing the photographing and
processing of the scene. They learned the basic details of the events leading up to Mr. Chasse’s
death, and then the lead investigators quickly moved to the arrest scene at NW 13th and NW
Everett.
The Detectives asked each of the involved officers, the sergeant and the deputy if they
would submit to an immediate interview about the incident and/or participate in a “walkthrough” of the scene, during which an officer will point out what happened where. Consistent
with usual practice and upon the advice of their union attorneys, each of the involved officers
and deputies declined to be interviewed that evening, although one of the involved officers
agreed to participate in a walk-through of the arrest scene. He pointed out to detectives the
location where he first saw Mr. Chasse and other critical locations in the incident. Detectives did
interview all of the witness officers that evening – that is, those who had not been directly
involved with the arrest of Mr. Chasse but had arrived at the scene soon after – as well as
deputies working at the Multnomah County Detention Center who had been present when Mr.
Chasse was first brought in by the arresting officers.
Detectives collected as evidence the deputy’s Taser and the defibrillator machine, among
other items. The Homicide sergeant determined that there were four separate paramedic teams
that had been involved with Mr. Chasse, two from AMR and two from Portland Fire Bureau, and
asked to have both AMR teams come to the Detective Division for interviews later that evening.
A representative for AMR, the private ambulance company, replied that the AMR paramedics
would not be willing to give statements to Homicide at that time.
The day following Mr. Chasse’s death, Detectives interviewed the sergeant originally
involved in the arrest of Mr. Chasse as well as the officer who first made physical contact with
3

Commanders of both the Transit Division and Central Precinct also responded to the scene that
evening.
14

him. They also attended the Medical Examiner’s autopsy where the Medical Examiner shared
her conclusions that blunt force chest injuries had caused Mr. Chasse’s death. She pointed out
multiple rib fractures and blood fluid in his left lung from penetration by broken ribs.
Detectives also made another attempt to arrange interviews with the AMR paramedics
and were told by a supervisor for the company that access to EMS staff would not be granted and
requested reports and records would have to be subpoenaed.
That day, Detectives interviewed the nurse at the jail who had refused to allow the
officers to book Mr. Chasse into the jail and had insisted that he be taken to the hospital for
evaluation.
The following day, two days after Mr. Chasse’s death, Detectives interviewed the
remaining officer and the deputy who had been among the original five officers who put hands
on Mr. Chasse during his arrest and transport to the jail as well as his transport to the hospital.
Over the next two weeks, Detectives interviewed 14 civilian witnesses. All of these
interviews were conducted by telephone. During this period, Detectives also conducted face-toface interviews with four Portland Fire Bureau personnel, employees of the City-operated
paramedic team that had responded to the arrest scene.
B. Organization and Pace of the Investigation
Homicide was notified by the Bureau when there was yet only a strong likelihood that a
death in custody investigation would be required. To his credit, the Homicide supervisor began
assembling a team immediately and, when he learned within a few minutes that the incident
involved multiple locations and more than one agency, he expanded the investigative team and
sent groups of detectives to the various scenes. The investigative team grew to six Detectives
and two sergeants working under Homicide’s umbrella plus four Detectives from the Sheriff’s
Office. The Detectives quickly identified the relevant witnesses, both sworn and civilian. There
was also careful documentation of evidence collection and attention to some potentially
important details, for instance, assigning a detective to accompany the involved officers’ car as it
was towed from the NE Clackamas Street scene and to document any personnel who opened it or
touched the interior during that process.
15

Some aspects of the investigation, however, appear to have proceeded more slowly. Two
of the five key sworn witnesses were not interviewed until two days after the incident. None of
the civilian eyewitness interviews were begun until four days after the incident. Some of them
took place several days later. Virtually all of them were conducted by telephone. While some of
these 14 civilians did not come forward until days after the incident, several were identified
immediately, especially the employees of the nearby restaurant. Given the large number of
nearby, independent witnesses to this daytime arrest, it likely would have been more productive
to interview these eyewitnesses earlier in the process. Because the immediate response by
Homicide investigators was not to the arrest scene, it may have been impracticable to conduct
eyewitness interviews by the time investigators arrived. However, if so, the impracticability of
such an approach should have been documented in the file. Additionally, in a case where lines
of sight and proximity to the action are important, telephone interviews are clearly less desirable
than a face-to-face interview, preferably at the scene.
Recommendation: The Bureau should consider adopting internal protocols for in-custody
death investigations that recognize the advantage of on-scene face-to-face interviews for
civilian eyewitnesses and the need to conduct those interviews shortly after the incident has
occurred if practicable. If conducting such interviews immediately after the event is not
practicable, that fact should be noted in the investigative file.
C. Delay of Involved Officer Interviews
The five primary officers involved in the arrest of Mr. Chasse – including two who
arrived after the foot pursuit and helped hobble and then carry Mr. Chasse – all declined to be
interviewed on the day of the incident. This is allowed by law during the criminal phase of the
investigation, as officers have a Fifth Amendment right to refuse to talk to a criminal
investigator. The general custom among PPB officers is to decline to be interviewed
immediately after the incident. Each of the PPB officers and the MCSO deputy followed that
pattern. This is regrettable in our opinion because the fresh impressions of the participants may
be lost with the passage of time. Moreover, the separation and chaperoning of involved officers
immediately after a critical incident, which PPB pursues conscientiously, is potentially rendered
ineffectual by an interview delay of one or two days. PPB employs a “Communication
16

Restriction during Investigation” form to admonish officers not to talk about the facts of the
incident with other officers before they are interviewed. This is a laudable way of documenting
this message but it does not adequately address the possible appearance of an opportunity for
officers to collude created by the delayed interviews of involved officers.
Recently, in support of law enforcement, a few academics have suggested that it may be
preferable to wait a day or more before obtaining a witness interview from officers involved in
critical incidents. The argument draws support from memory studies that suggest individuals
involved in a high stress incident may actually have a better ability to articulate and recall certain
events a day or two after the incident, once the stress of the situation has dissipated. If these
studies are true, it would suggest that best investigative practices should uniformly avoid
interviewing any witness about a stressful incident until a day or two has lapsed. However, we
have seen no similar protocol being advocated that would uniformly delay for a day or two a
witness interview of a bank teller who was victimized by a bank robber, a witness interview of
the victim of an aggravated assault, or an interview of a person who witnessed a carjacking, even
in cases in which the suspect has been apprehended. To carve out an investigative “wait”
exception so that law enforcement officers, persons especially trained to be professional
witnesses, can collect their thoughts before telling their Bureau what occurred runs against
general investigative principles that call for obtaining early statements from witnesses and gives
too little weight to the abilities of police officers to relate such information relatively quickly.
Another argument toward preserving the status quo is that in Portland police officers
have regularly agreed to be voluntarily interviewed by Homicide investigators, albeit a day or
two delayed, and that to attempt to change current protocols could cause officers to no longer
agree to a voluntary interview. Of course, the Bureau could compel officers to submit to
interviews the night of the incident; but that interview would not be available to the District
Attorney. While certainly there is value in obtaining voluntary interviews, one must weigh the
advantage of having a voluntary interview a day or two after the incident against gaining an
account from the involved officers the night of the incident. Moreover, in our experience, the
concern that officers will stop agreeing to voluntary interviews if interviewing protocols are
modified usually is not borne out. There are certainly inherent advantages for officers to agree to
17

voluntary interviews and provide to the District Attorney his or her version of what occurred,
particularly in the vast majority of cases that do not come close to implicating criminal conduct.
To suggest that officers will stop providing this information to the District Attorney if the Bureau
wants to obtain the information the night of the incident may undervalue the officers’ interest in
having his or her version of the event readily available to the District Attorney.
This being said, we have been informed that the current Bureau labor contract provides
that involved officers are not to be interviewed contemporaneous with the incident. We also
understand that union attorneys have been more accommodating recently and have allowed
Detectives to interview officers the day after the incident, as occurred with regard to some of the
involved personnel in this case. However, protocols that would afford the Bureau to be able to
obtain a statement from officers the night of the incident about what had transpired would help
the fact finding process and provide increased public trust in the Bureau’s critical incident
investigations.
Recommendation: The Bureau should consider initiating discussions with the union to
reform protocols so that involved personnel can be interviewed about their actions
contemporaneous with the incident.
Additionally, we observed that the sequestering/monitoring of the officers back at the
precinct after the incident was well documented but there was no documentation of their
transportation from the scene.
Recommendation: The Bureau should consider revising internal investigative protocols so
that the transport of officers from the scene is documented.
As noted above, one of the involved officers did agree to participate in a walk-through of
the arrest scene immediately. The walk-through and any statements made by the officer were
only scantily documented, as Detectives strove to avoid any suggestion that they were attempting
to interview the officer.4 Nonetheless, the walk-through doubtless provided the Detectives with

4

If a walk-through begins to resemble a full-blown interview, there is a greater likelihood that
the officers will decline to participate.
18

a very useful early picture of the location and general outlines of the arrest. The Detectives do
not indicate why they did not ask the officer to walk through the NE Clackamas Street scene
also, though it seems logical that the officer might very well have been willing to do for both
scenes what he had just done for one.
The Detectives’ interviews were generally focused, thorough, and unbiased. We
observed some use of arguably leading questions, such as when one officer was asked if he
noticed if another officer had picked something up off the ground as evidence, but no overtly
suggestive or coercive questioning. We observed one potentially important oversight in the
interviews of the officer and deputy who initiated the chase and apprehension of Mr. Chasse as
well as performing chest compressions on him later. Both interviews took place soon after the
Homicide Detectives attended the autopsy and spoke to the medical examiner. They were aware
that the medical examiner had determined that the cause of death was blunt force injuries to the
chest and ribs and that many ribs were fractured. It is logical to expect that this should have
caused Detectives to focus more intently upon the initial take down and the use of chest
compressions during CPR at the NE Clackamas Street scene. The interviews of the officer and
the deputy however spent little time on this part of the action. They did not delve into the
sensations or sounds that might have emanated from Mr. Chasse’s chest and did not grapple with
how these routine police actions could have produced what would have seemed at the time like
disparately great chest injuries.
At least one witness who was not interviewed, however, represents a small but
conspicuous gap in the Detective investigation. One of the two nurses at the jail, who apparently
had the opportunity to make observations and evaluations of Mr. Chasse, was not interviewed.
She might have been able to address some crucial questions about the arrestee’s symptoms and
appearance and any statements made by the involved personnel about the arrest incident.
As noted above, Detectives identified the two ambulance paramedic teams and attempted
to interview them on the night of the incident. The AMR paramedics, apparently on the advice
of their employer, declined. The Homicide team persisted the next day and spoke to an AMR
supervisor, to no avail. They tried again when a detective encountered the company attorney at
the Grand Jury proceedings, again without success. This evident interest in the fresh statements
19

of the AMR personnel was certainly well placed given their presence and participation at two
critical points in the chain of events that ended with Mr. Chasse’s death. Their vital vantage
point and expertise makes their refusal to participate in the investigation all the more
disappointing. While ambulance paramedics form part of the emergency services infrastructure,
they are not public employees and in this instance their employer’s concerns about liability
evidently took precedence over all other concerns. The Homicide Detectives made an earnest
and persistent effort to persuade the company to cooperate but their appeal to civic duty
evidently did not carry sufficient weight to overcome those concerns. Given the key role that
ambulance personnel may likely play in future critical incidents as participants, as medical
experts and as experienced witnesses independent of law enforcement, it behooves the Bureau
and the City to consider initiating discussions with the private ambulance company to determine
whether protocols can be adopted ensuring the cooperation of personnel with any subsequent
PPB in-custody death investigation.5
Recommendation: The Bureau and the City should consider initiating dialogue with AMR
to develop protocols ensuring future cooperation of the private ambulance company in PPB
in-custody death investigations.
D. Personnel Responding to Scene
The Internal Affairs Division has not regularly responded to the scene of critical
incidents. We have been informed that, in the past, IAD personnel did respond to some scenes
but IAD command found little advantage to doing so. It is unclear to what degree IAD personnel
who did respond had access to the scene and whether they were able to participate in a walkthrough or obtain an on-scene briefing by Homicide Detectives. Moreover, as noted elsewhere
in this report, IAD only recently began actively conducting its own investigation as opposed to
simply repackaging the Homicide investigation. With its enhanced duties, the advantages of
5

To their credit, responding personnel from the Portland Fire Department did agree to be
interviewed by Homicide Detectives. With regard to the two ambulance crews from AMR,
while they were eventually subpoenaed and testified before the grand jury, it would have been
helpful to the investigation if Homicide had been afforded an opportunity to interview personnel
prior to their grand jury testimony.
20

IAD personnel being able to observe conditions close in time to the incident rather than to have
to rely entirely on photographs, diagrams, or investigative reports is greater than in years past.
Moreover, the more active role IAD is playing in independently developing facts related to
administrative issues calls for a presence at the scene so that it can dialogue with its Detective
counterparts and ensure that evidence that may be unimportant for purposes of the criminal
review is collected and preserved for purposes of the administrative investigation.6
It would have been advantageous to have IAD investigators present at the scene in the
Chasse case for a number of reasons. First, IAD investigators would have had early access to the
basic facts of the incident, somewhat mitigating the fact that IAD did not receive the Homicide
Detectives’ notebook until four months after the Grand Jury. Also, IAD investigators would
have been in a better position to identify witnesses and gather information concerning the
allegation that officers were behaving improperly and spreading misinformation about Mr.
Chasse, an issue that was peripheral to Homicide’s task. Finally, IAD investigators would have
been able to identify witnesses from MCDC and, if not interview them, at least consult with
Detectives about the scope of questioning.
It is our understanding that IPR is currently involved in discussions with the Bureau that
may result in IPR regularly responding to the scene of critical incidents. We support this
initiative. As a result of the increased role being played by IPR in ensuring thorough
investigations and reviews of critical incidents, it will be helpful for IPR to travel to the scene to
gain an early understanding of the potential issues presented by the incident. Moreover, the
rapid response evidenced by IPR rolling out to these incidents provides both a real and symbolic
message to the public of IPR and City Auditor’s commitment to its responsibilities and is
indicative of a robust independent oversight mechanism.
The likely regular presence of IPR at critical incident scenes is yet another reason for the
Bureau to consider again having an IAD representative travel to the scene. In most cases, IPR’s
ability to identify issues and provide real-time advice regarding critical incidents is conveyed
6

Some police agencies have policies ensuring dialogue at the scene between criminal and
administrative investigators so that evidence important to the administrative case is timely
collected.
21

through IAD. As the incident unfolds and issues become known to IPR, the Bureau would be
well-served to have IAD also present at the location to discuss these issues with IPR.
Recommendation: The Bureau should consider revisiting the idea of having IAD
representatives respond to in-custody death scenes. The Bureau should continue to work
with IPR to develop protocols so that IPR can become a regular part of the response to incustody death scenes.
V.

Internal Affairs Division Investigation
A. Timeline of the Investigation
Following the conclusion of the criminal case, investigators from the Internal Affairs

Division (“IAD”) were assigned to investigate Mr. Chasse’s death administratively, looking at
the question of whether officers had violated any PPB policies in their contact with Mr. Chasse.
Unfortunately, it took IAD approximately seven months to begin its work, and then it confronted
delays associated with the ongoing civil litigation, so that IAD did not complete its investigation
until July 2008 – 22 months after Mr. Chasse’s death.
The initial delays in the IAD investigation stemmed from what appear to be both
systemic and individualized problems within PPB. When Detective Division completes its
investigation, it quickly hands its materials over to the District Attorney’s office so the case can
be presented to the grand jury. Once the urgency of grand jury presentation no longer exists,
though, it typically takes several months for Detectives to complete the criminal case notebook
for distribution to IAD and others in the Bureau. Thus, although the grand jury returned a no
true bill (decided not to indict the involved individuals) in October, 2006, IAD did not receive
the case notebook until the end of December, 2006. PPB reports to us that this customary time
gap has decreased in the nearly four years since this incident, so that IAD now receives the
Detectives’ notebook in a more timely fashion.
Recommendation: The Bureau should consider creating an internal policy that would set a
realistic but certain deadline by which the Detectives’ notebook must be presented to IAD.
Divergences from such an internal policy should be based on good cause and only after
obtaining written approval at the Assistant Chief level.
22

In this case, however, it may not have mattered how quickly IAD received the
Detectives’ investigatory materials, because personnel issues within IAD created another four
month delay. It was reported to us that during the relevant time period in 2006 and 2007, IAD
was staffed at significantly less than its usual strength and was operating with a vacancy in its
lieutenant position due to a retirement. We were informed that PPB had pulled sergeants out of
IAD to work other, mainly patrol, assignments to contend with a Bureau-wide staffing shortage.
In February, 2007, PPB addressed this problem by filling IAD positions with civilians (mainly
investigators retired from PPB or other law enforcement agencies), but the interim period and
transition time left IAD short-staffed for the critical time during which the Chasse investigation
should have been moving forward. We applaud the Bureau’s decision to staff IAD with
civilians, insulating IAD from the vagaries of future staffing crises. Another benefit of using
retired PPB investigators to perform IAD investigations is that the Bureau benefits from having
personnel experienced in Bureau processes and procedures yet those personnel, who are
ineligible for further career advancement, are less likely to be affected by external influences
than officers who are looking for promotional opportunities might be.
Recommendation: The Bureau should consider drafting internal policies recognizing the
critical importance of a robust IAD function and ensuring that resources not be diverted
away from this unit.
IAD investigators assigned to the Chasse case began conducting interviews in May, 2007,
interviewing the Medical Examiner and the responding paramedics from AMR. They then
learned in July, 2007, that the Multnomah County Attorney’s office would not permit the
Sheriff’s deputies or other personnel involved in the incident to be interviewed until after the
plaintiff’s attorney had taken their depositions in the civil case. The reason provided for this
refusal was that the County did not want additional statements to be obtained that might be used
by the plaintiff’s attorney. It was also asserted by the County that the deposition testimony
would fully answer any remaining questions that IAD investigators had. At this point, the IAD
case stalled. IAD investigators had planned to interview the deputies prior to interviewing the
involved PPB officers, and, in consultation with their supervisors – including an Assistant Chief
– decided to stay with this plan and wait until the depositions were completed. When the
23

depositions were postponed from September, 2007 to January, 2008, the PPB reconsidered its
position, and investigators interviewed the two involved PPB officers in November and
December, 2007. This was already over a year after the incident.
The plaintiffs’ attorney took the depositions of the involved officers and deputies in
January, 2008, and the Multnomah County attorney handling the case finally made the deputies
available to be interviewed in April, 2008. Investigators conducted those two interviews in May,
and completed the initial draft of their case in June, 2008. Following review by IAD supervisors
and the IPR, the case was completed in July, 2008. See the timeline attached at the end of this
Report for a complete view of the entire investigation and review process.
B. Quality of the Investigation
The IAD investigation consisted of nine interviews – the Medical Examiner (interviewed
twice), the two AMR paramedics who responded to the NW 13th and NW Everett scene, the two
involved PPB officers and one involved deputy, a deputy from MCDC, and one civilian witness.
Investigators attempted to contact two other civilian witnesses, but the witnesses did not respond
to interview requests.7 They prepared a 47-page report summarizing their work and a
PowerPoint presentation for the Use of Force Review Board.
Overall, we found the work done by IAD investigators to be very good. The interviews
conducted were thoroughly probing and largely devoid of problematic leading questions.
Importantly, the questioning by IAD investigators took a broad view of the incident, looking
beyond the question of whether the officers’ use of force was appropriate to the broader issues
regarding officers’ tactical decisions and adherence to policy both before and after the force
incident. Investigators aggressively questioned the officer and deputy about the bases for their
decision to contact Mr. Chasse and then to pursue him on foot and take him to the ground. They
also thoroughly questioned the sergeant, officer, and deputy about their interaction with
paramedics and the decision to transport Mr. Chasse to the jail rather than have the ambulance
take him to the hospital. Again regarding transport decisions, they questioned the officers about
7

As with other police agencies, IAD investigators do not have authority to compel civilian
witnesses to be interviewed.
24

the information they received from nurses at MCDC and the decision to return Mr. Chasse to
their radio car rather than calling for an ambulance. Investigators’ attention to each of these
issues in their interviews with the involved officers assisted the Use of Force Review Board
members in having a complete picture of the officers’ states of mind at each of these critical
junctures.
Investigators also thoroughly interviewed the AMR paramedics about their assessment of
Mr. Chasse and, as importantly, the information provided to them by officers at the scene.
Information gained from the paramedics prompted investigators to re-interview the Medical
Examiner so she could clarify her earlier opinions. Though Detectives had interviewed 14
civilian witnesses, IAD sought to re-interview the three that appeared to have the most detailed
information about the incident. Two did not respond to attempts to reach them, and investigators
traveled to Oakland, California to interview the third.8 The amount of independent work
conducted by IAD demonstrates clear recognition by the Bureau that IAD should no longer rely
entirely on the investigative work of the Detectives and merely repackage that work for
administrative purposes. It is important to note that it was not too long in PPB’s past when the
simple repackaging approach was standard operating procedure for critical incident
investigations.
While the interviews conducted were fair and thorough, we did find important missing
pieces in the investigation. First, IAD investigators should have interviewed each of the PPB
officers who responded to the NW 13th and NW Everett scene, and in particular, those officers
who assisted in restraining Mr. Chasse and carrying him to the patrol car. While Detectives had
interviewed these officers, IAD had new information from the coroner regarding the possible
effects of the way in which Mr. Chasse had been carried.
In addition, we found that IAD could have done more to investigate allegations by citizen
witnesses that officers and/or paramedics had been laughing and joking at the scene. While IAD
investigators did ask those interviewed about these allegations with little result, because they did
8

We have been informed that PPB’s authorization for IAD investigators to travel out of state to
interview a civilian witness was unprecedented. We credit PPB for this commitment to fact
gathering for purposes of the administrative process.
25

not interview all officers at the scene, we cannot conclude the investigation was as thorough as it
should or could have been on this point. The same is true regarding an allegation that an
unidentified officer told a bystander that Mr. Chasse was on drugs and had prior drug-related
convictions. Though IAD investigators had information regarding the patrol car in which this
officer was seated when he allegedly made those comments, they were instructed to complete
their investigation before interviewing the officer to whom that vehicle was assigned. It is not
clear whether this decision was the result of a rush to complete the investigation once the
litigation-related delays had ended, a belief that further investigation on this point was likely to
be fruitless, a lack of regard for the importance of the allegation, or a combination of the three.
It would have been important to know whether the information allegedly passed on to the
witness about Mr. Chasse originated with the involved officer or deputy or was generated from
some other source. The allegation, if established, could suggest that there was a conscious or
unconscious attempt to taint civilian witnesses with inaccurate information about the arrestee. If
it could be verified that these comments were made, while there could also be innocent
explanations for how this information was passed on to a witness, it was potentially relevant to
the credibility of the officer or deputy and could have been indicative of an after-the-fact attempt
to justify their pursuit and arrest of Mr. Chasse.
IAD investigators also did not fully explore the short delay in getting Mr. Chasse into the
jail while the involved officer and deputy completed paperwork in a parking lot across the street
from the jail. As a result, it was unclear why the officers chose to leave Mr. Chasse in maximum
restraints in the back seat of the patrol car rather than carry him into the jail immediately and fill
out the paperwork at that time.
Investigators also did not interview the MCDC nurses who observed Mr. Chasse at the
jail, and only interviewed one of the deputies assigned to the jail who encountered Mr. Chasse,
though it is clear that numerous jail deputies and other personnel had contact with Mr. Chasse
and conversations with the officer and deputy who brought him in. We cannot be too critical of
IAD for these particular omissions, however, because it is apparent that Multnomah County, who
would not allow the involved deputy to be interviewed until he had been deposed, may have
placed even greater restrictions on IAD when it came to interviewing the jail personnel.
26

Nonetheless, in the interests of conducting an entirely complete investigation, investigators
should have requested these interviews and documented any refusal from the County.
The most glaring deficiency in the IAD investigation, though, was the failure to do
everything possible to enhance the audio portion of a video taken at MCDC that depicts the
involved officer and deputy recounting or reenacting their confrontation on the street with Mr.
Chasse. The audio in the original recording is mostly unintelligible, but during the course of
litigation, the parties were able to have it enhanced to a point where you can fairly clearly hear
the officer say he “tackled” Mr. Chasse, seeming to contradict his statements to IAD that he had
pushed Mr. Chasse to the ground, particularly when taken together with the deputy’s gestures
indicating a wrap-around type of tackle. The audio was not enhanced, though, until the IAD
investigation was complete and the Use of Force Review Board had met to vote on its
recommendations to the Chief. 9
At that point, IAD had to wait until the Detectives conducted a criminal investigation
considering the truthfulness of the involved officer, then wait further until the District Attorney
had opined on the allegation, and then had to reconsider the allegations regarding the officer’s
truthfulness for administrative purposes. The Chief decided to wait to act on the Board’s
recommendation until the supplemental investigation was completed to learn whether that
additional information might alter the Board’s original recommendations. In the end, the failure
to recognize the potential importance of the video and act on it early caused the case to drag on
for an additional 10 months. That failure, however, should not be attributed to line investigators.
Rather, we have been informed that the decision to not work harder to enhance the audio portion
of the video was made further up the chain of command. Though we were unable to get a
consistent explanation from the numerous people we spoke to on this issue, two things seemed to
have motivated that decision – cost and the sense that it was not too important a piece of
evidence. Neither is an adequate explanation, given the gravity of this case and the central issue
9

We were informed that some work to enhance the video had been attempted by PPB’s own
forensic unit early in the case, but that the results were unsatisfactory. To the degree this
occurred, it was not sufficiently documented in the file and the end result in which the audio was
considerably enhanced suggests that insufficient emphasis was placed on this evidence.
27

of the officer’s credibility. It is unsettling that a private plaintiffs’ attorney was the driving force
behind PPB’s ultimate recognition of the importance of the video as evidence.
In addition, even if technology to enhance the audio track was prohibitively expensive,
the unenhanced video shows numerous jail personnel listening to and watching the officer and
deputy tell their story. As noted above, PPB could have sought to interview these individuals
prior to the close of the IAD case, but did not.
We also note that the missing pieces in the IAD investigation referenced here could have
been recognized and possibly remedied by IPR in its oversight role. However, this observation
must be considered in the context of the evolution of IPR’s role in shaping critical incident
investigations. Since 2006, that role has continued to enlarge, and while IPR did, in fact, offer
helpful suggestions and input to IAD regarding some of the issues presented in the Chasse case,
the input of IPR in critical incident investigations had not matured to the point where it is today.
C. Delays and Lessons Learned
As with the decision about enhancing the jail video, the other delays in the IAD
investigation were mostly out of the control of the individual investigators. IAD staffing issues
and decisions made around the inability to interview the involved MCSO deputy were broader
Bureau concerns.
There are several lessons the Bureau can learn from this incident related to the challenges
surrounding the delays stemming from the litigation. First, the PPB should make (and to some
degree already has made) agreements with the other participating agencies in the Transit Police
Division regarding their obligation to cooperate in PPB investigations. (See Section XIII.
Transit Police Division Challenges, below).
Second, the Bureau should recognize the cost of delaying an investigation and consider
how best to weigh those costs against competing factors. Here, the Bureau10 decided first not to
10

In recognition of the uniqueness of this case, decisions about who to interview and when were
not made by investigators, but by their supervisors, at times all the way up to the Assistant Chief
level.
28

conduct an interview of its own sergeant and officer until it could interview the involved deputy.
This decision was later reversed and investigators were allowed to proceed with interviews prior
to the deputy’s participation, but not until more than a year had passed from the time of Mr.
Chasse’s death.
Ordinarily, best investigative practices dictate that the initial criminal interview of
involved personnel or witnesses does not suffice for purposes of the administrative interview.
Moreover, those practices suggest that investigators should proceed to interview involved
persons in ascending order of the degree of involvement of each individual. Accordingly, it was
sound investigative practice for IAD to devise a plan to interview the deputy first and then
interview the PPB sergeant and officer.
That plan ran into a major snag, however, when the Assistant County Attorney
announced that she was preventing the deputy from being interviewed until after he was deposed
in the civil litigation, a delay that ended up being nearly a year. At this point, the Bureau was
faced with various courses of action, none of which were ideal.
First, when initially encountering resistance by County authorities to the interview, PPB
could have raised this issue with its Commissioner and/or the Council as a whole. The initial
resistance by the County lawyer to have the deputy interviewed may have been overcome as a
result of the involvement of the City’s elected officials in discussions with their counterparts in
County government. Such discussions might have better framed the issue of ensuring timely
internal fact gathering for the benefit of the Bureau and the Portland community at large.
Because this was not considered, we will never know whether such an approach and potential
dialogue may have ended the logjam.
Recommendation: In critical incident investigations where outside government agencies
place roadblocks on access to information or witnesses, PPB should consider enlisting the
assistance of its Commissioner and/or City Council to help remove those roadblocks.
A second option available to PPB was to move forward with the IAD investigation
without interviewing the involved deputy. Fortunately, Detectives had already extensively
interviewed the deputy, and PPB had that interview available for purposes of the IAD
29

investigation. While there certainly were subjects relevant to an administrative investigation that
were not directly broached by the criminal Detectives, PPB might have internally asked whether
the potential additional information that would be obtained by a delayed IAD interview was
worth the delay. This inquiry becomes particularly germane considering that by the time IAD
was permitted by the County Attorney to interview the deputy, nearly two years had passed from
the time of the incident and the deputy had spent numerous hours preparing for and then giving a
deposition, calling into question how helpful and pure such an interview could be at that point.11
Recommendation: In critical incident investigations where outside entities successfully
prevent timely access to important witnesses, PPB should consider the evidence already
obtained from the witness, the potential value in obtaining delayed information from the
witness(es) in question, and determine whether the IAD investigation should proceed
without the additional information.
It is unfortunate that PPB was faced with this dilemma as a result of the County
Attorney’s hands-off position regarding IAD’s access to the deputy, even after he became a PPB
employee.12 The County Attorney’s position runs counter to progressive practices in defining
the relationship between the need for internal fact gathering and the need to defend the
government entity from civil litigation. For most progressive agencies, the balance is struck in
favor of fact gathering rather than having the internal investigative process shut down and
dictated by the pace of civil litigation. The County Attorney’s focus on the County’s fiscal
interests delayed the Bureau’s search for truth, hampered its ability to formulate a systemic
11

Strategic decisions and advice on how to answer questions posed during a deposition by
plaintiff’s counsel are not intended to produce and unvarnished and candid recitation of the
witnesses’ observations.
12

We were informed that even after the deputy had left the MCSO and was working for the
Bureau, the Assistant County Attorney suggested that were he to be interviewed before his
deposition, any resulting judgment from the civil litigation might need to be paid from his own
pocket. In a meeting involving executives at the Bureau’s highest levels, the Bureau decided not
to compel the former deputy to be interviewed and risk his exposure to that liability. As noted
above, in retrospect, it probably would have been better for the Bureau to present this issue to the
Police Commissioner or other elected officials for possible input and intervention.
30

response, and significantly slowed its decision making on individual accountability for its
employees.
Most concerning is that such a perspective may be applied beyond this case to other
witnesses in future incidents. As noted above, the County also did not allow one of its deputies
working in the jail to be interviewed until he had been deposed. Other potential witnesses to the
officer and deputy statements and actions in the jail were also not interviewed by IAD, probably
because of the hands-off approach adopted by the County attorneys for the first two County
witnesses that IAD wanted to interview. Accordingly, if this case can be seen as a prologue to
future inaccessibility of County employees, it portends future hamstringing of PPB in-custody
death investigations.
One way in which PPB could protect itself from a similar future stymie would be to
develop an understanding that, in critical incident investigations in which non-PPB witnesses
may have important information, criminal Detectives need to expand their initial questioning of
these witnesses to include potential administrative issues. These issues are potentially relevant to
the criminal investigation as well but are oftentimes reserved for the IAD investigators. Now
that PPB knows that outside entities may place these witnesses outside the reach of its IAD
investigation, it should move to ensure that its Detective personnel obtain the information as part
of their criminal probe. Should outside government entities resist interview requests by the
criminal detectives, those witnesses can be subpoenaed to testify before the grand jury.
Homicide Detectives can then ensure that their testimony is recorded and retrieve a copy of the
tape or transcript of the grand jury proceedings.
Recommendation: In shootings and in-custody deaths involving members of outside law
enforcement agencies as either participants or witnesses, Detectives should be instructed
and trained to question these individuals regarding administrative issues when they
interview those outside members, on the assumption that IAD may not be able to timely
interview them.

31

VI. Training Division Analysis and Recommendations
The Training Division reviews all officer involved shootings and in-custody deaths,
summarizing each involved officer’s training background and analyzing each aspect of the
incident to reach a conclusion about whether each officer’s actions were consistent with
applicable training doctrines. Typically, the Training Division’s analysis is prepared by a
sergeant, but because of the gravity of the Chasse case, the Training Captain – with the Chief’s
concurrence – appointed a seasoned lieutenant to handle the review of this matter.
The Training Division review in the Chasse case is a 22-page document that analyzes in
detail each of the decisions made by the involved sergeant, officer, and deputy as they
encountered and apprehended Mr. Chasse. It examines the entire incident and describes the
training each PPB officer receives relevant to each of the critical decision points. It concludes
that two of the officer’s decisions were inconsistent with the Training Division’s Tactical
Doctrine. First, it states the officer should have advised dispatch of the location and
circumstances prior to contacting Mr. Chasse. Second, the Training analysis concludes that,
even though the officer and deputy had reason to contact Mr. Chasse based on the belief he had
urinated in public, initiating a foot pursuit and then knocking Mr. Chasse down was inconsistent
with training because the officer did not adequately consider the severity of the alleged crime
and the risk to public safety. The Training analysis also discusses the deputy’s application of the
Taser as being less than ideal but not improper, but declines to reach a conclusion based on the
fact that the deputy was not, at that time, a PPB member.
Perhaps even more important than its analysis of the officer’s performance is Training’s
identification of “lessons learned” to be disseminated to the Bureau in a meaningful and helpful
way. The Training Division document in the Chasse case concludes with eight
recommendations, all of which the Bureau has implemented:

•

Provide the 40-hour Crisis Intervention Team (“CIT”) training to all uniformed
officers and sergeants.

32

•

Revise emergency medical procedures to give greater direction to Bureau
members in advising EMS personnel and deciding how to transport subjects.
(Addressed in Directive 630.45, effective January 30, 2007)

•

Provide additional in-service training regarding person encounters and the use of
physical force.

•

Update Advanced Academy Training to include CIT training and reinforce person
encounters and applicable statutes and policies relating to foot pursuits.

•

Develop and disseminate a roll-call video pertaining to foot pursuits, highlighting
the dangers of pursuits and the knock-down technique.

•

Develop and disseminate a roll call video discussing the proper application of the
Taser at close quarters.

•

Expand the Training Division’s Foot Pursuit Tactical Doctrine to provide
additional emphasis on the need to consider at the outset the severity of the crime,
applicable statutes and policies, knowledge of the subject, including physical
descriptors, and the immediate environment.

•

Send members to the National Sudden Death and Excited Delirium Conference.

The document prepared by the Training Division is impressive in its detail and
thoughtfulness. In relation to the work conducted by other comparable police agencies in
identification of systemic issues, the product emanating from the Bureau is remarkable. For too
many police departments, the identification of systemic issues coming out of critical incidents is,
at best, uneven and idiosyncratic.
We are extremely impressed with the Bureau’s willingness to quickly implement these
recommendations without waiting for completion of the investigation or any orders deriving
from the litigation. The Bureau’s resolve to identify the multitude of systemic issues stemming
from Mr. Chasse’s death, develop remedial measures, and ensure timely implementation of those
recommendations for reform is testament to PPB performing at its highest level. We have
33

reviewed many other critical incidents for comparable law enforcement agencies and the
evidence of resolve by PPB executives to timely implement the recommended reforms is one of
the most impressive that we have seen.
That being said, as we note elsewhere, there were two additional issues emanating from
the Chasse incident that were not addressed by the Training analysis – the involved supervisors
failure to relinquish command of the incident to another responding sergeant and officers’
decision to carry Mr. Chasse to the patrol vehicle while in maximum restraints. This fact does
not contradict our assessment of the Bureau’s processes relative to other police agencies – we
dare say that many similarly situated police agencies that do not possess the robustness of the
Bureau’s processes could well have neglected to identify and address even the eight
recommendations that were identified.
One equipment issue that was not addressed by Training is whether the Bureau expects
that breathing guards should be standard equipment in patrol cars and readily available to
officers. As noted above, when Mr. Chasse began showing signs of distress, the deputy stopped
the car and attempted to administer aid. The deputy attempted to locate a breathing guard in the
trunk of the patrol car, but could not find one. While this lack of equipment likely did not have
impact on the final tragic result, there was no discussion in the Training analysis about this
equipment issue and how it might hamper officers’ ability to provide first aid in future incidents.
In our discussion of this issue with PPB executives, we were told that the Bureau now requires
that each patrol car be outfitted with a breathing guard.
VII.

Unit Commander’s Review

When the IAD case and Training Analysis are complete, they are sent with the
Detectives’ notebook to the Commander of the involved officer(s) Responsibility Unit (“RU
manager”) for his or her review and findings. Here, the Commander who had been in charge of
Transit at the time of Mr. Chasse’s death concluded that all of the sergeant’s and officer’s actions
in this incident were within policy. Her analysis tracked the incident chronologically and
evaluated the foot pursuit and takedown, the use of force in restraining Mr. Chasse, the decision
to put him in maximum restraints and take him to jail, and the decision to transport him from the
jail to the hospital. The major emphasis of the Commander’s four-and-a-half page analysis is on
34

the officer’s decision to pursue and take Mr. Chasse to the ground. Most notably, it discusses the
officer’s legal right to stop and arrest or cite Mr. Chasse for indecent exposure in connection
with the officer’s belief that Mr. Chasse had urinated in public and his further belief that Mr.
Chasse’s odd behaviors were related to narcotics use. It cites the large number of complaints
Transit Division receives regarding drug dealing on and around the transit system and the
Division’s proactive response in attempting to eradicate drug dealing and other nuisance
behaviors.
As we discuss below (Section XIII. Transit Police Division Challenges), we heard from
numerous sources that the Transit Division had a particular way of doing business that set it apart
from the rest of the Bureau and seemed to give license to tactics not supported by Training or
condoned in other divisions. We also heard that this was a direct response to community
expectations and Transit Division’s mission to eliminate drug sales and nuisance crimes from on
and around the transit system. Aware that this would be an issue likely raised in the officer’s
defense, Bureau command staff responsible for IAD proposed expanding IAD’s investigation to
examine the role of supervisors and executives who may have been instructing or tacitly
allowing Transit Division officers to in effect diverge from their training and Bureau policies in
pursuit of their mission, but was instructed not to by supervisors up his chain of command.
In our experience, tactical decision making by individual officers in critical incidents
often can be attributed to supervisory instruction that is at odds with agency practices. When
evidence of this exists, it can often excuse the officer’s performance in whole or in part.
However, such evidence must be fully explored during the investigation so the agency can
remedy the situation and, when appropriate, hold those supervisors accountable for poor
direction. It is unfortunate that, in this case, IAD investigators apparently were directed away
from pursuing this investigative strategy.
Recommendation: In cases where tactical decision making may have resulted from a lapse
of supervision, the Bureau should encourage rather than limit IAD’s development of these
issues in its investigation.
Based on our discussions with Bureau executives, it appears this recommendation may
already have begun to be addressed. The Bureau understands that supervision is an important
35

element of critical incidents and that facts regarding those supervisory issues must be collected in
order for them to be assessed. We have learned that the Bureau has recently approved a new
format for memos from the Review Board that automatically triggers the question of whether
supervisory issues should be assessed, and we are hopeful this will serve as a signal to IAD that
the Bureau intends for investigators to gather these facts so that the Board can conduct a robust
review of these issues.
VIII. Use of Force Review Board
A. Chasse Review Board
In the Chasse case, the Use of Force Review Board (“UFRB”) convened twice – first for
two days on October 1 and 2, 2008, to discuss the initial question of whether the PPB sergeant
and/or officer who, together with the MCSO deputy, first made contact with Mr. Chasse violated
any PPB policies and to consider the systemic recommendations advanced by Training. The
Board met again on September 16, 2009, to discuss whether evidence brought to light following
the enhancement of the jail video in any way changed the Board’s initial findings.
At the time, the UFRB was a 14-member Board (with eight voting and six non-voting
members) that served as an advisory body to the Chief. The UFRB reviews officer-involved
shootings, in-custody deaths, and certain other force cases and recommends to the Chief findings
on whether or not the force used was within PPB policies. In addition, the Board may comment
on the adequacy of the investigation and the Responsibility Unit manager’s findings, ask for
additional investigation, recommend action items, and consider performance issues. The board
also reviews systemic recommendations put forward by Training Division and considers whether
to recommend implementation of those reforms to the Chief.
The UFRB’s first meeting in the Chasse case was an unusually long affair, 10 hours over
two days. It first heard a joint presentation from Detectives who handled the homicide
investigation and IAD investigators responsible for the administrative investigation. Training
Division then presented its analysis. One issue arose during this Board meeting when the
president of the officer’s union (who regularly attends and is allowed to speak at meetings, but is
not a Board member) questioned the Training Division Lieutenant about the apparent fact that a
36

well-respected Training officer disagreed with his finding that the decision to pursue Mr. Chasse
was inconsistent with training. It is unclear how this exchange affected the Board’s decision.
In the end, the UFRB determined the officer’s actions throughout the incident to be
within policy, but concluded the sergeant had violated the Bureau’s policy regarding medical
treatment for subjects following application of the Taser (Directive 1051.00) and recommended
that all three involved members be debriefed on this issue. On the question of whether the foot
pursuit of Mr. Chasse was within policy, there was only one dissenting voting member who
believed, consistent with the Training analysis, that the officer did not adequately consider the
safety of the officers, public, or Mr. Chasse in deciding to initiate the pursuit. The opinion
conveyed in the memo from the Transit Division Commander – that discipline for the officer’s
decision to pursue would be inappropriate because the officer was taking the kind of proactive,
aggressive police action his supervisors at Transit encouraged – apparently trumped the Training
Division analysis and carried the day with the Board. Several Board members and others in the
Bureau with knowledge of the case acknowledged that the Board was reluctant to recommend
discipline for the involved officer for initiating the foot pursuit and taking Mr. Chasse to the
ground because he was acting in accordance with Transit’s mission to eradicate drug dealing and
other nuisance behaviors on and around the trains, even if it was contrary to the Bureau’s
training expectations. (See Section XIII. Transit Police Division Challenges, below).
The Chasse UFRB reconvened in September, 2009 to vote on whether the additional
investigation surrounding the enhancement of the jail video caused members to change their
initial votes. IAD did a brief presentation and the Board viewed the enhanced jail video a
number of times. Notably absent from the supplemental review, though, was a revised Training
Division Analysis. The initial Training analysis assumed as true the officer’s statement that he
used the “knock down technique” taught by Training as a preferred way of terminating foot
pursuits. The new evidence suggested that the officer tackled Mr. Chasse in more of a “bear
hug” fashion, an approach that presumably was inconsistent with Training. The reconvened
Board did not hear any opinion from Training regarding the impact of the additional
investigation on its analysis.

37

When votes were tallied, a near-unanimous Board determined that nothing in the
additional investigation should change the original recommendation. There was, unfortunately,
significant confusion regarding this unprecedented process. Some Board members reported they
had no clear sense of direction as to why they were there a second time or what their role was
supposed to be. They did not have access to the supplemental IAD investigation prior to the
meeting, as even the Board’s organizers seemed uncertain as to the appropriate way to handle
this supplemental or secondary review. Moreover, as reported above, no supplemental training
analysis was prepared or presented to the Board. Based on our interviews and document review,
there appears to have been a strong feeling that the Bureau needed to quickly resolve this
supplemental issue so that it could put this case behind them and move on.
Recommendation: The Bureau should consider modifying Use of Force Review Board
protocols so that in cases in which new evidence is developed and considered by the Use of
Force Review Board, the Training Division should be contacted to determine whether a
supplemental analysis and presentation to the Board is warranted.
B. Use of Force Review Board Structural Issues
Passage of a new Police Review Board ordinance this spring (City Code and Charter
Chapter 3.20.140), coupled with a new Police Chief, provides the Bureau the opportunity to
refine and redefine the UFRB. The biggest change is to the composition of the Board, which
will now have seven voting members and nine advisory members, and will be chaired by a
Review Board Facilitator who is not a member of the Board. The IPR Director, previously a
non-voting member, now has a vote.
As noted in PARC’s Second Follow-Up Report (December 2006), the Bureau has
adopted many of the recommendations for the UFRB from prior PARC reports in Bureau
Directive 335.00. The new ordinance reinforces those improvements over prior review
processes, and codifies some important changes, such as the requirement that the Board prepare a
detailed statement of its recommended findings and proposed discipline, including a record of its
vote, an explanation of its rationale, and details of any minority position.

38

One PARC recommendation from the December 2006 report that has not been
implemented called for a procedure for notifying all UFRB members of the final outcomes of the
cases in which they participate. We support this recommendation. Failure to inform members of
final outcomes demonstrates a lack of appreciation especially for the citizen volunteers’ time and
efforts and represents a missed learning opportunity in those cases where the Chief and/or
Commissioner diverge from the Board’s recommendation. For cases that proceed to arbitration,
the final decision and any resulting analysis would inform Board members on how any
recommendations were considered by an outside entity. Finally, demonstrative evidence of the
Bureau’s implementation of any training or policy recommendations proposed by the Board
would demonstrate how the Board can be an effective change agent for the Bureau.
Recommendation: The Bureau should consider revising its protocols so that all UFRB
members are notified of the final outcomes of the cases in which they participate.
During our review, we also learned of a concern over the availability of investigative
materials during Board meetings. Citizen and peer members of the Board do not receive copies
of the investigation, but are required to review the materials in the Chief’s office in the weeks
prior to the UFRB. During the Board meetings, the Assistant Chiefs have copies of the materials
available for review during the meeting. In the past, if a citizen or peer member wanted to
reference something from the investigation, he or she had to borrow an Assistant Chief’s book.
We were pleased to be informed that this has very recently changed, and the Bureau now makes
additional copies of the investigative materials available so that all Board members can readily
access a given transcript or diagram during the meeting.
Finally, we question the Bureau’s preference for having involved officers attend the
UFRB. Board members reportedly find it helpful to hear an account directly from the officer.13
Throughout our review, we heard from several about the value of having officers attend Board
meetings and the disappointment over the more recent trend of officers declining the invitation,

13

One way to ameliorate some Board members’ concerns that simply reading a transcript of the
officers’ interviews is overly sterile would be to make the interview tapes available for listening
prior to the convening of the Board.
39

as they did in the Chasse case. Indeed, we learned that Bureau executives made significant
efforts to have the involved officer appear before the UFRB in this case.
Though we have never attended a UFRB meeting and our experience with PPB is limited
to review of this case, we are concerned about the Board’s eagerness to question or take
statements from involved officers. In our view, the officers’ statements or response to questions
are just as likely to muddy as to clarify the facts. During both the criminal and IAD
investigations, the officer is given the opportunity to present any pertinent facts when he or she is
interviewed. Sometimes an officer who has had the opportunity to review the case files
following his or her interview can clarify matters that were not obvious to him or her at the time
of the interview and the system does allow for this, with the opportunity to schedule a mitigation
meeting with the Chief after the issuance of the UFRB recommendations. But from what we
have heard, officers who attend UFRB meetings are most likely to put forward an emotional
rather than factual appeal, and those who have clearly violated policy but do not accept
responsibility and plead for a merciful recommendation are judged harshly. Of course, others
emotionally impacted by the critical incident – family members of the decedent, advocates, or
citizen witnesses – do not have the opportunity to similarly address the Board in person. If the
Board is intended to be a dispassionate fact finding body, the necessarily emotion-laced impact
that results when involved personnel appear before the Bureau-dominated Board seems to run
contrary to that intent.
Recommendation: The Bureau should reconsider the advisability of encouraging an
involved officer to appear before the UFRB. At a minimum, if officers do continue to
sometimes attend UFRB meetings, the Bureau should consider requiring the facilitator to
prevent emotional appeals and ensure that officers and Board members limit the discussion
to factual issues.
IX. The Bureau’s Corrective Actions
Following Mr. Chasse’s death, the Bureau took initiative in implementing a number of
new policies, practices, and training protocols to address some of the issues raised by this
incident. We applaud the Bureau’s initiative and offer a few suggestions for improvement.
40

A. Policies
1. Emergency Medical Custody Transport Directive
Most immediately, in January, 2007, the Bureau implemented a new policy regarding the
transport of injured or ill subjects. It provides clearer guidance to officers confronting decisions
about when to transport subjects to jail and when ambulance transport to the hospital is required,
both at the scene and at MCDC booking. The policy places on EMS personnel at the scene the
responsibility for determining whether an in-custody subject requires ambulance transport to a
hospital or can be transported to jail by officers. Addressing two concerns about the events
surrounding Mr. Chasse’s treatment, it also clearly requires officers to provide EMS personnel
complete and thorough information regarding any force used against the subject, and prohibits
officers from signing medical transport refusal forms on behalf of subjects.
The policy also states that EMS will provide officers with a copy of the Pre-hospital
Medical Treatment Worksheet whenever the subject is to be transported to jail. Officers are
required to provide the Worksheet to medical staff at MCDC. If medical staff refuses to admit a
subject, the medical official is supposed to document that refusal and determine the appropriate
mode of transport. If the medical staff refuses to admit a subject and determines that the subject
can be transported via patrol vehicle, the officer is to document the refusal and notify a sergeant.
In general, the Medical Transport policy is an extremely positive effort toward providing
clarity in challenging situations, and we applaud the Bureau for quickly addressing the issues so
clearly raised by Mr. Chasse’s death. However, we did find some of the language to be a bit
unclear and unenforceable. In particular, the policy purports to require EMS personnel and
MCDC medical staff to provide documentation, but those individuals are neither trained in nor
bound by PPB policies. The policy would do better to require PPB officers to request the
documentation and notify a sergeant of any refusal. In addition, the policy does not squarely
address the precise situation the involved officer and sergeant confronted here – where EMS
personnel cleared Mr. Chasse for transport to the jail while at the same time offering to transport
him to the hospital, leaving it up to the involved sergeant to determine what would be best for

41

Mr. Chasse.14 Ideally, EMS personnel would make that decision. Where they refuse, the best
policy would either default to requiring EMS transport or, at a minimum, require the responding
sergeant to document the information he or she provided to EMS and articulate the reasons for
permitting officers to transport.
Recommendation: The Bureau should consider refinements to the Emergency Medical
Custody Transport Directive to more clearly define PPB officers’ responsibilities.
2. Revised Use of Force Policy
Two months following Mr. Chasse’s death, the IPR and PPB convened a Task Force to
study, report on, and make recommendations regarding the use of force by PPB members. We
have been informed the Force Task Force was not convened in direct response to the Chasse
incident but had been planned in response to earlier troubling incidents. Nonetheless, to the
extent this case contributed at all to the urgency or content of the discussion, the Bureau should
be credited for moving forward in a positive way. The Task Force made a series of
recommendations that ultimately resulted in a revised Physical Force policy (Directive 1010.20)
in March 2008. The policy is laudable for a number of provisions, including its main
requirement that members use only that force “reasonably necessary under the totality of the
circumstances to perform their duties and resolve confrontations effectively and safely” even
when higher levels of force may be legally allowable. The Task Force was reconvened in 2009
and found the Bureau had implemented all of the recommendations emanating from the earlier
report.
3. Foot Pursuit Policy
Two months prior to Mr. Chasse’s death, the Chief issued an Executive Order regarding
foot pursuits (published in January, 2007 as Directive 630.15). The Directive is an excellent
policy statement on the dangers of foot pursuits and contains a number of cautions and
prohibitions designed to promote officer safety. The policy was borne out of PARC
14

We have concerns about the involved sergeant stepping into the role of incident commander
and coordinating the EMS response after having been directly involved in the force incident.
(See Section X. Supervisory Issues, below).
42

recommendations and a concern about the frequency with which officer involved shootings are
preceded by foot pursuits. The policy talks generally about the officer’s need to be aware of the
degree of risk to which the officer exposes himself or herself and others, then speaks specifically
to factors dealing with armed suspects and the tactics officers should employ when pursuing
suspects. Among the factors to be considered when initiating/continuing a foot pursuit, it does
not enumerate those factors which would have been most relevant to the decision to pursue Mr.
Chasse – the severity of the crime for which the suspect is being pursued, applicable statutes and
policies, and the benefit of the suspect’s capture. The Training Division has expanded its
Tactical Doctrine to include these factors.
Recommendation: Consistent with its revised Tactical Doctrine, the Bureau should
consider revising its foot pursuit policy to include additional factors officers should weigh
in deciding whether to initiate or continue a foot pursuit.
4. Mobile Crisis Unit
In April, 2010, the PPB’s Operations Branch, working with Project Respond, established
a Mobile Crisis Unit that teams a Project Respond mental health clinician with a PPB officer.
Their objectives are to respond to service calls involving individuals in a mental health crisis,
provide follow-up on referrals from field officers or Project Respond clinicians, provide onscene mental health consultation and assessment in critical incidents, and conduct proactive
investigations involving transient persons who appear to be suffering from a mental illness with
the goal of directing them to services. The unit operates only within the Central Precinct and its
operating procedures are intended to cover a one-year trial period after which the program will
be analyzed to assess whether it should be made permanent. It is certainly too soon to say
whether this program will be effective, but the Bureau deserves praise for its willingness to work
with the mental health community in an effort to find creative solutions to a sometimes
seemingly intractable problem.

43

B. Training
1. CIT Training
Perhaps the most impressive response the Bureau made to the Chasse incident was its
commitment to provide the 40-hour Crisis Intervention Team (CIT) training to all of its
uniformed officers and sergeants. To complete such extensive training of nearly 1,000 members
within 15 months of this incident was a remarkable accomplishment of which the Bureau should
be proud.
We have been informed that there has been reluctance by the Bureau to open this training
to non-Bureau members because to do so could chill participants’ willingness to share personal
experiences. While we understand that outside observers can inhibit candid dialogue, we wonder
whether at least some of the class could be opened up to the public without undercutting its value
to the participants.
Recommendation: In the interest of transparency, the Bureau should consider whether a
portion of its CIT training could occasionally be opened and training materials made
available to interested members of the public.
2. Videos, Bulletins, and In-Service Training
In response to the Chasse case, the Training Division targeted subsequent in-service
training on use of force issues, updated its Advanced Academy Training to regularly feature
scenarios, including CIT-related problems, and produced a number of videos and briefings. As
part of our analysis, we reviewed a number of roll-call videos, “Tips and Techniques” briefings,
and course materials relevant to the Chasse case, including: Foot Pursuits, highlighting the
dangers of foot pursuits and the knock-down technique; Taser use in close quarters with a
violently struggling individual; Hobble Review/Excited Delirium, instructing officers on the
carry and transport of subjects in maximum restraints; and Emergency Medical Transport
Directive. We found these materials, particularly the videos, to be of very high quality.
We noted that the Bureau has in the past used specific incidents as the basis for training
videos, including one video we reviewed that discussed the problems associated with another in44

custody death. While we recognize the emotions surrounding the Chasse case may make it
difficult for the Bureau to consider using it in training materials, utilizing the whole event as a
learning tool may prove invaluable, not just to the officers who receive the training, but to the
entire Bureau, as a signal it has learned from the challenges presented in this case.
Recommendation: The Bureau should consider whether the circumstances surrounding
the Chasse case can be developed into a training video for the benefit of all Bureau
members.
C. Foot Pursuit Data Collection and Tracking
Following the first Use of Force Review Board in October, 2007, the Chief directed the
Office of Accountability and Professional Standards to begin tracking foot pursuit data,
including when, why, how often, and with what results officers chase suspects. It is our
understanding that this project is ongoing, but moving slowly because of the need to change the
data collection forms to gather the relevant information. With the recent restructuring of OAPS
under the new Chief, the status of this project is unclear. We recommend the Bureau continue
this project to give its managers a clearer picture of where and under what circumstances officers
engage in the most high-risk foot pursuits. In the interests of transparency, the Bureau should
share this data with the public as it becomes available.
Recommendation: The foot pursuit data collection and tracking initiative should continue
to be supported by the Bureau and the data developed from the initiative should be
periodically made available to the public.
X. Supervisory Issues
The sergeant involved in the force incident assumed a role as incident commander once
Mr. Chasse was restrained, taking responsibility for coordinating the responses of other units,
speaking with concerned members of the public, communicating with responding EMS
personnel, and identifying and interviewing witnesses. While not prohibited by any policy or
specific training, common sense should have dictated that another supervisor assume
responsibility for these tasks. Indeed, another sergeant did respond to the scene, but reported that
the involved sergeant was at the scene and seemed to be in control. The second sergeant assisted
45

with getting Mr. Chasse into the patrol car and then left the involved sergeant at the scene to
contact witnesses and coordinate any further response. No doubt the involved sergeant had been
affected by the struggle with Mr. Chasse and the fact that he had been bitten on the leg. His
adrenaline was likely elevated, and he may have been physically impacted and almost certainly
emotionally tied to the outcome in a way that the uninvolved sergeant would not have been.
Ideally, the involved sergeant, along with the officer and deputy, should have reported their uses
of force to the responding sergeant, who should have assumed command of the incident and, in
particular, communicated with paramedics and made the decision about whether to transport Mr.
Chasse to jail or send him to the hospital via ambulance.
This issue, though identified by some in the Bureau, was not raised in the Training
Division analysis, nor has it been addressed by subsequent corrective actions.
Recommendation: The Bureau should consider devising a Directive requiring any sergeant
or lieutenant involved in a significant use of force incident to relinquish his or her role as
supervisor once the force incident is over and to call for another supervisor to respond to
the scene and assume command of the response to the incident. Any supervisor who
responds to an incident in which another supervisor has been involved also should have a
concomitant duty to assume command and relieve the involved sergeant or lieutenant of his
or her on-scene responsibilities.
XI. The Decision to Carry Mr. Chasse to the Patrol Vehicle
Once the sergeant made the decision to have Mr. Chasse transported to jail, he and three
other officers carried Mr. Chasse in the maximum restraint position back to the officer and
deputy’s patrol car, a distance of approximately 30 – 40 feet. They carried him face-down, with
one officer at each of his armpits and one officer at each leg. The officers describe that during
the carry Mr. Chasse was struggling and pulling against the restraints. The officers placed Mr.
Chasse into the patrol car and transported him to the jail. He was still in maximum restraints, so
he was strapped into the backseat of the vehicle, lying on his side. At the jail, the officer and jail
deputies carried him in the same manner into a cell.

46

The Medical Examiner opined that the manner in which Mr. Chasse was carried may
have exacerbated his rib fractures, displacing them and causing his punctured lung. As
evidenced by the Medical Examiner’s opinion, carrying a struggling individual by his extremities
places inordinate strain on the body. It is puzzling in this case why officers decided to carry a
struggling Mr. Chasse the entire distance of the pursuit, when it would have been easier to drive
a patrol car closer to the location where he was brought into custody. The Medical Examiner’s
opinion should have caused IAD to focus on this issue as critical, but, unfortunately, the manner
in which Mr. Chasse was carried was not fully explored by investigators, who did not interview
all of the Bureau officers involved in carrying Mr. Chasse.
This lack of focus on this part of the episode carried over to the Training Division
analysis.15 In particular, there was no discussion in the analysis about whether it would have
been preferable to shorten the distance in which the struggling Mr. Chasse was carried to
minimize the likelihood that his injuries would be exacerbated. In addition, there was no
discussion in the analysis about whether alternative approaches should have been devised
regarding the manner in which he was carried. As a result, the Use of Force Review Board
offered no recommendations regarding systemic reform of this aspect of the encounter.
If a person must be moved while in maximum restraints, best practice is to let medical
personnel transport, so the person can be placed on a gurney to fully support his or her body
weight and then monitored by medical personnel. At a minimum, best practices dictate that
subjects not be transported in patrol vehicles in maximum restraints, but should have the
maximum restraint removed and the hobble secured to the vehicle so that the individual’s legs
are still restrained but he or she can sit upright. If subjects must be carried, officers should
minimize the distance they need to be carried.

15

This is understandable, in part, because the Training Division analysis in this case was
completed before the IAD investigation, so it is possible that Training did not even know about
the Medical Examiner’s opinion on this point prior to preparing its analysis.
47

Recommendation: The Bureau should consider revising its policies and training to prohibit
officers’ transport of subjects in maximum restraints. It should also review its policy and
training on carrying subjects in maximum restraints, explore alternative methods for
moving subjects, and modify its training doctrines accordingly so that officers are at least
instructed to minimize the distance they carry subjects in maximum restraints.
XII.

Personnel Issues

A. PPB Hiring of Involved Deputy
While the IAD investigation was still pending, the Bureau hired the involved deputy to be
a PPB officer. His application for a lateral move from the MCSO was pending at the time of the
incident and moved forward despite his involvement. This decision was not made unknowingly
or by accident, but was a deliberate decision made at the Bureau’s highest level. Regardless of
how attractive a candidate the deputy may have been, it is not a preferred practice to hire
someone who is the subject16 of a pending administrative investigation. To do so suggests that
the Bureau had foreordained the outcome of the IAD investigation, at least with regard to the
performance of the deputy.
Recommendation: The Bureau should consider adopting a policy of not hiring lateral
candidates from other law enforcement agencies while they are the subjects of pending
administrative investigations.
B. Assignment/Status of Officers during Pending Investigation
Following the Grand Jury, the involved officer returned to a Transit Division assignment.
He was involved subsequently in another use of force that, while controversial on its own,
became even more so as a result of his involvement in the Chasse case.
Mainly in response to recent officer-involved shootings, the Bureau recently
implemented a policy requiring that members directly involved in fatal shootings be placed in
16

The deputy was technically not a subject of IAD’s investigation, but only because he was not a
member of PPB at the time of the incident. MCSO did not conduct its own administrative
investigation regarding the deputy’s actions.
48

administrative assignments for at least one month following the Grand Jury, subject to month-tomonth review by the member’s division commander and Assistant Chief. This policy is
advantageous in that it first treats all involved members the same and then allows for
individualized treatment. Most importantly, it provides Bureau members prior guidance and
expectations regarding how they are going to be deployed following a deadly force event.
Recommendation: The Bureau should consider extending this administrative assignment
policy to officers involved in in-custody deaths.
XIII. Transit Police Division Challenges
The Transit Police Division is a multi-jurisdictional division under the command of the
PPB responsible for providing police services on and around the rail and bus lines of the TriCounty Metropolitan Transportation District (“TriMet”). During our review, we heard from
many sources that at the time of the Chasse incident, the Transit Division may have been
operating under a different set of standards than the rest of PPB. There also was a belief that
Transit had a unique mission in responding to the public’s complaints about drug dealing and
other nuisance behaviors on and around the transit system. For example, we learned that IPR
was concerned even before the Chasse incident about the number of complaints it had received
from people regarding the frequency with which Transit officers chased people and pushed them
down.
In explaining the germination of the Transit Division culture, people reported an
emphasis at the Division on addressing drug use and sales, as well as other nuisance issues, on
and around the trains. Second, there was apparent concern that protracted foot pursuits and
struggles with suspects near train lines would be dangerous because of the heightened risk of
death should someone be on the tracks when a train came by. As a result, officers frequently
chased suspects for minor crimes and attempted to very quickly shove them to the ground using
the knock down technique.
Finally, it was expressed to us that at the time of the Chasse incident, Transit Division
command staff largely allowed officers and first line supervisors in the field to develop their own
priorities and ways of doing business. As a result, questions were raised about how effectively
49

the Transit Division command was ensuring that its officers’ mission was consistent with both
the Division and Bureau’s mission. This phenomenon may have further widened the gap
between Bureau expectations and Transit-specific practice and, as discussed elsewhere in this
Report, the circumstance described was eventually used in the Chasse case as a defense and
justification for the involved officer’s decision making and tactical performance. Following the
Chasse case, PPB reportedly dealt with these issues through changes in leadership at the Transit
Division. We have been told that recent data suggests the Division is currently more in line with
PPB expectations.
If, in fact, the Bureau has since 2006 effectively closed the gap between Bureau
expectations and Transit-specific practice, there still remain challenges as a result of its current
makeup that are deserving of further consideration. Transit is a multi-jurisdictional division,
currently with officers and deputies from 14 other local law enforcement agencies working with
the PPB under the authority of a PPB Commander. The multi-agency nature of Transit presents
a number of challenges for the Bureau. The first is public confusion. Particularly in downtown
Portland, where the most Transit activity occurs, citizens assume that Transit officers are PPB
officers and assign blame to the Bureau when they have complaints, even though the reality is
that there are nearly twice as many Transit officers from other agencies as there are from the
PPB.17
More troubling issues relate to differences in the ways participating agencies hold their
officers accountable. The Intergovernmental Agreements (“IGA”) between TriMet, the City of
Portland, and participating agencies provide that citizen complaints will be routed to the subject
officer’s agency and require each agency to maintain an accountability system through which
those complaints will be investigated and evaluated. The agreements call for agencies to conduct
joint investigations “when necessary and appropriate.” Though we were told by PPB executives
that there now exists an understanding that some participating agencies will permit PPB to
handle administrative investigations, there is no formal agreement. The IGA we reviewed
contains no specific provision even requiring the other agency to participate or cooperate in a
17

Currently, of 45 Transit officers, only 16 are PPB employees; and of 13 supervisors (sergeants
and lieutenants), five are from PPB.
50

PPB investigation, and no requirement that another agency conduct an investigation in a
particular type of case (shootings or in-custody deaths, for example), let alone have its officers
cooperate in a PPB investigation.
The Chasse case presents an example of the problems created when two officers from
different agencies are involved in a critical incident. Multnomah County’s litigation concerns
hamstrung the PPB IAD investigation, while at the same time, because MCSO chose not to
conduct a formal Internal Affairs investigation of its own, the deputy’s performance was never
reviewed to determine whether there were any violations of policy or training issues. In the
Chasse case, the deputy did not play as significant a role as the PPB officer or sergeant, but it is
not difficult to imagine a scenario where two officers from different agencies are equally
culpable for some type of violation of policy or a poor tactical decision but only one is held to
account.
Recommendation: The Bureau should consider initiating a dialogue with TriMet and
participating agencies to forge an agreement that participating agencies will ensure
complete and timely cooperation of their personnel, including an agreement to be promptly
interviewed in any subsequent PPB criminal or Internal Affairs Division investigation.
Any agreement should include specific language that ongoing civil litigation should not be a
reason for refusing to provide PPB timely access to these individuals.
Inconsistencies in training and policy matters complicate PPB’s ability to hold Transit
officers accountable and more importantly, to ensure a coordinated and uniform tactical response
to a dynamic unfolding event such as the Chasse incident. Each non-PPB officer is trained
according to his or her agency’s policies and procedures.18 Without reviewing the manuals of
each participating agency, we can guarantee that there are significant differences between those
policies and those of PPB, whether regarding what force is reportable, how to conduct high-risk
stops, or what each agency’s expectations are regarding whether and how to go into foot pursuit.
Accordingly, when a PPB officer is paired with an officer from another agency, there may well
18

All Transit Police Division officers do receive PPB in-service training, but this is presented as
a sort of refresher course training and does not expose officers from other jurisdictions to PPB
tactical high risk training and protocols in a systematic, comprehensive way.
51

be uncertainty about which agencies’ “playbook” is being used. Because the two officers are
working off of different training experiences and different manual provisions, they may well
have a divergent perspective on how to respond to emergent situations such as the Chasse case.
For example, a PPB officer may be trained to use greater caution and be required to
communicate with dispatch before going into a foot pursuit, while an officer from a participating
agency may not operate under such expectations. When a Portland officer points his or her gun
at someone, he or she must report that as a force incident; other participating agencies do not
have such a reporting requirement. The fact that Transit officers are differently trained and work
under divergent policy expectations presents the real potential that those officers will react
differently and not complementarily in their approach to dynamic situations.
Labor agreements and practical realities likely make it infeasible for participating
agencies to agree to require their officers assigned to Transit to be subject to all of PPB’s policies
and be part of PPB’s complete training regimen. (The PBB Manual of Policy and Procedure is a
589-page book.) However, PPB could isolate key operational and tactical policies and training
doctrines that all Transit officers could then be expected to follow. The Bureau could develop a
focused training program to provide new Transit officers an understanding of these core policies.
Recommendation: The Bureau should consider the potential challenges, coordination, and
uniformity issues presented by the multi-jurisdictional nature of the Transit Division and
work with its counterparts to ensure all Transit officers have been trained in and will be
held accountable to a set of core policies and key tactical training doctrines to better ensure
that when officers are presented with dynamic events, there is a pre-existing, coordinated,
and consistent understanding of how each participant will respond to that event.
XIV. Transparency
In our meetings with community members, we heard questions about IPR’s role in officer
involved shooting and in-custody death investigations. In this case in particular, some
community members were frustrated by the slow pace of the investigation and their inability to
learn from the Bureau how the investigation was proceeding. Indeed, the Bureau’s reputation
suffered from the public’s reliance on the media for information about the case. While the Chief
did issue press releases containing detailed information, including a four-page “Fact Sheet” in
52

October, 2006, immediately following the Grand Jury’s no true bill, some members of the
Portland community apparently reacted with skepticism to the information issuing from the
Bureau.
IPR’s ability to report to the public details regarding the investigation into Mr. Chasse’s
death certainly was limited during the pendency of that investigation, but it may have been able
to report on its role in the investigation and subsequent UFRB and offer its assurance either that
the investigation and review would be fair and thorough or that IPR would, at some point, inform
the public of shortcomings. Indeed, the citizens we spoke with remain confused about IPR’s role
in this case. Part of this confusion stems from IPR’s changed and enlarged role in reviewing
critical incident cases. Certainly, in practice IPR’s role in 2006 with regard to critical incidents
was not the same as it is now. And its role continues to grow and shift with enactment of new
Police Review Board and Independent Police Review Division ordinances (City Code & Charter
3.20.140 and 3.21) effective April, 2010. To the extent possible given the limits of its statutory
authority and confidentiality obligations, IPR should try to increase public trust by disseminating
information regarding the status of investigations and its role in attempting to ensure that the
investigation will be fair and thorough and that the Bureau will reach principled decisions. Such
information from the perspective of an independent entity would go a long way toward retaining
the public’s trust in the integrity of the process. In addition, IPR’s response to the scene of
critical incidents will also bolster the public’s confidence in IPR’s ability to effectively oversee
the Bureau’s investigations of these incidents.
Recommendation: IPR should consider whether it is appropriate to establish a more
visible presence during the pendency of critical incident investigations to assure the public
that an independent entity will be helping to shape the investigation and participating in
the review to ensure thorough, fair and principled fact gathering and outcomes.
The City has a long and admirable tradition of seeking outside review of critical
incidents. Members of the Bureau with whom we spoke expressed widespread appreciation for
the value of independent review of these incidents. However, the practice has traditionally
included long delays waiting for the conclusion of civil litigation before initiating outside review.
In our view, this has greatly diminished its potential benefits. We support the City Auditor’s
53

decision to initiate the review of the Chasse incident prior to the conclusion of the litigation, and
hope she continues that practice going forward.
Recommendation: Outside review of critical incidents should not be dictated by the pace of
any resulting litigation.

54

Investigation and Review Timeline
September 17, 2006

Mr. Chasse’s death

October 2006

Grand Jury convenes; returns no true bill

December 2006

Meeting with Detectives, IAD, and Training to discuss case

January 2007

IAD and Training receive Detectives’ notebook

May 2007

IAD begins conducting interviews

July 2007

Multnomah County Counsel advises IAD that MCSO deputy assigned to
jail could not be interviewed until after depositions in September

September 2007

Multnomah County Counsel advises IAD that depositions postponed until
January 2008 and that involved MCSO deputy and deputy assigned to jail
could not be interviewed until after depositions; PPB executives decide to
put IAD investigation on hold pending interviews of MCSO deputies

October 2007

Training Analysis completed; PPB executives reverse course and advise
IAD to proceed with investigation

November 2007 December 2007

IAD interviews involved PPB sergeant, civilian witness, and involved
PPB officer

April 2008

Multnomah County Counsel authorizes interviews of MCSO deputies

May 2008

IAD interviews MCSO deputy and former deputy

June 2008

IAD investigation completed

July 2008

IAD revises case following input from IPR

August 2008

Transit Bureau Commander findings completed

September 2008

Assistant Chief findings completed

October 2008

Use of Force Review Board meeting

November 2008

Chief’s memo adopting Training recommendations and delaying
disciplinary decision until additional allegations regarding officer’s
truthfulness resolved

May 2009

Detectives’ investigation completed; DA declination regarding
perjury/untruthfulness allegation

June 2009

IAD case regarding untruthfulness allegation completed

August 2009

Transit Bureau Commander findings regarding untruthfulness allegation

September 2009

Second UFRB meets; Chief issues press release announcing UFRB
findings and suspension of involved sergeant

November 2009

Police Commissioner issues press release announcing decision that both
sergeant and involved officer would be suspended

55

OIR Group’s Recommendations Based on the Review of the Closed Investigations of the
In-Custody Death of James Chasse (July 2010)

Homicide Detectives’ Investigation
Recommendation 1: The Bureau should consider adopting internal protocols for in-custody death
investigations that recognize the advantage of on-scene face-to-face interviews for civilian
eyewitnesses and the need to conduct those interviews shortly after the incident has occurred if
practicable. If conducting such interviews immediately after the event is not practicable, that
fact should be noted in the investigative file.
Recommendation 2: The Bureau should consider initiating discussions with the union to reform
protocols so that involved personnel can be interviewed about their actions contemporaneous
with the incident.
Recommendation 3: The Bureau should consider revising internal investigative protocols so that
the transport of officers from the scene is documented.
Recommendation 4: The Bureau and the City should consider initiating dialogue with AMR to
develop protocols ensuring future cooperation of the private ambulance company in PPB incustody death investigations.
Recommendation 5: The Bureau should consider revisiting the idea of having IAD
representatives respond to in-custody death scenes. The Bureau should continue to work with
IPR to develop protocols so that IPR can become a regular part of the response to in-custody
death scenes.
Internal Affairs Division Investigation
Recommendation 6: The Bureau should consider creating an internal policy that would set a
realistic but certain deadline by which the Detectives’ notebook must be presented to IAD.
Divergences from such an internal policy should be based on good cause and only after obtaining
written approval at the Assistant Chief level.
56

Recommendation 7: The Bureau should consider drafting internal policies recognizing the
critical importance of a robust IAD function and ensuring that resources not be diverted away
from this unit.
Recommendation 8: In critical incident investigations where outside government agencies place
roadblocks on access to information or witnesses, PPB should consider enlisting the assistance of
its Commissioner and/or City Council to help remove those roadblocks.
Recommendation 9: In critical incident investigations where outside entities successfully prevent
timely access to important witnesses, PPB should consider the evidence already obtained from
the witness, the potential value in obtaining delayed information from the witness(es) in
question, and determine whether the IAD investigation should proceed without the additional
information.
Recommendation 10: In shootings and in-custody deaths involving members of outside law
enforcement agencies as either participants or witnesses, Detectives should be instructed and
trained to question these individuals regarding administrative issues when they interview those
outside members, on the assumption that IAD may not be able to timely interview them.
Unit Commander’s Review
Recommendation 11: In cases where tactical decision making may have resulted from a lapse of
supervision, the Bureau should encourage rather than limit IAD’s development of these issues in
its investigation.
Use of Force Review Board
Recommendation 12: The Bureau should consider modifying Use of Force Review Board
protocols so that in cases in which new evidence is developed and considered by the Use of
Force Review Board, the Training Division should be contacted to determine whether a
supplemental analysis and presentation to the Board is warranted.
Recommendation 13: The Bureau should consider revising its protocols so that all UFRB
members are notified of the final outcomes of the cases in which they participate.
57

Recommendation 14: The Bureau should reconsider the advisability of encouraging an involved
officer to appear before the UFRB. At a minimum, if officers do continue to sometimes attend
UFRB meetings, the Bureau should consider requiring the facilitator to prevent emotional
appeals and ensure that officers and Board members limit the discussion to factual issues.
The Bureau’s Corrective Actions
Recommendation 15: The Bureau should consider refinements to the Emergency Medical
Custody Transport Directive to more clearly define PPB officers’ responsibilities.
Recommendation 16: Consistent with its revised Tactical Doctrine, the Bureau should consider
revising its foot pursuit policy to include additional factors officers should weigh in deciding
whether to initiate or continue a foot pursuit.
Recommendation 17: In the interest of transparency, the Bureau should consider whether a
portion of its CIT training could occasionally be opened and training materials made available to
interested members of the public.
Recommendation 18: The Bureau should consider whether the circumstances surrounding the
Chasse case can be developed into a training video for the benefit of all Bureau members.
Recommendation 19: The foot pursuit data collection and tracking initiative should continue to
be supported by the Bureau and the data developed from the initiative should be periodically
made available to the public.
Supervisory Issues
Recommendation 20: The Bureau should consider devising a Directive requiring any sergeant or
lieutenant involved in a significant use of force incident to relinquish his or her role as supervisor
once the force incident is over and to call for another supervisor to respond to the scene and
assume command of the response to the incident. Any supervisor who responds to an incident in
which another supervisor has been involved also should have a concomitant duty to assume
command and relieve the involved sergeant or lieutenant of his or her on-scene responsibilities.

58

The Decision to Carry Mr. Chasse to the Patrol Vehicle
Recommendation 21: The Bureau should consider revising its policies and training to prohibit
officers’ transport of subjects in maximum restraints. It should also review its policy and
training on carrying subjects in maximum restraints, explore alternative methods for moving
subjects, and modify its training doctrines accordingly so that officers are at least instructed to
minimize the distance they carry subjects in maximum restraints.
Personnel Issues
Recommendation 22: The Bureau should consider adopting a policy of not hiring lateral
candidates from other law enforcement agencies while they are the subjects of pending
administrative investigations.
Recommendation 23: The Bureau should consider extending its administrative assignment
policy to officers involved in in-custody deaths.
Transit Police Division Challenges
Recommendation 24: The Bureau should consider initiating a dialogue with TriMet and
participating agencies to forge an agreement that participating agencies will ensure complete and
timely cooperation of their personnel, including an agreement to be promptly interviewed in any
subsequent PPB criminal or Internal Affairs Division investigation. Any agreement should
include specific language that ongoing civil litigation should not be a reason for refusing to
provide PPB timely access to these individuals.
Recommendation 25: The Bureau should consider the potential challenges, coordination, and
uniformity issues presented by the multi-jurisdictional nature of the Transit Division and work
with its counterparts to ensure all Transit officers have been trained in and will be held
accountable to a set of core policies and key tactical training doctrines to better ensure that when
officers are presented with dynamic events, there is a pre-existing, coordinated, and consistent
understanding of how each participant will respond to that event.

59

Transparency
Recommendation 26: IPR should consider whether it is appropriate to establish a more visible
presence during the pendency of critical incident investigations to assure the public that an
independent entity will be helping to shape the investigation and participating in the review to
ensure thorough, fair and principled fact gathering and outcomes.
Recommendation 27: Outside review of critical incidents should not be dictated by the pace of
any resulting litigation.

60

Responses to the Report

OFFICE OF MAYOR SAM ADAMS
CITY OF PORTLAND

July 22, 2009
LaVonne Griffin-Valade
City Auditor
1221 SW 4th Avenue, Room 140
Portland, Oregon 97204
Subject: Mayor Adams’ response to the Office of Independent Review Groups’ report on the Chasse
investigation
Dear Auditor Griffin-Valade,
I would like to thank the Portland City Auditor for overseeing the completion of an independent review of
James Chasse's tragic death on September 17, 2006. While nothing in this report can erase the
emotional pain for Mr. Chasse's family and friends, a comprehensive examination of Portland Police
Bureau policies and procedures provides an opportunity to reflect and advance with an improved
understanding of the challenges facing citizens suffering from mentally illness. I am pleased with the
Bureau’s cooperation with the independent review process and the report’s recognition that the Bureau
opened up “its vault of materials and personnel to exacting outside review."
The report contains several suggested recommendations which merit additional investigation and
potential implementation. However, the report also highlights the progress the Bureau has made since
this tragedy occurred in 2006. Mr. Chasse's death, several changes have already been implemented
within the Bureau including the following:





Mandatory Crisis Intervention Team training for all officers;
Training officers to consider the severity of the crime before initiating a foot pursuit;
Requiring officers to give paramedics complete information before deciding how to transport
subjects; and
Roll call videos on foot pursuits, Taser use, and other subjects.

The report further states that the Bureau's Training Division Analysis and Recommendations contained
"eight specific recommendations, all of which the Bureau has implemented." I am encouraged by the
report's acknowledgment that "the Bureau's resolve to identify the multitude of systemic issues stemming
from Mr. Chasse's death, develop remedial measures, and ensure timely implementation of those
recommendations for reform is testament to PPB performing at its highest level."
It is my goal as Mayor and Police Commissioner to ensure that the Bureau continues to make substantial
progress in its treatment of all people in the City of Portland. I look forward to working with the Bureau to
implement additional changes in the future.
Best Regards,

Sam Adams
Mayor
City of Portland
1221

340 • PORTLAND, OREGON 97204
(503) 823-4120. mayorsamadams.com

SW FOURTH AVENUE, SUITE

Bureau of Police
Sam Adams, Mayor
Michael Reese, Chief of Police
1111 S.W. 2nd Avenue. Portland, OR 97204. Phone: 503-823-0000. Fax: 503-823-0342
Integrity • Compassion • Accountability • Respect • Excellence • Service

July 22, 2010

Ms. LaVonne Griffin-Valade
City Auditor
1221 S.W. 4th Avenue, Room 310
Portland, OR 97204

Subject: Portland Police response to the Office of Independent Review Group’s report on the
Chasse investigation

Dear Ms. Griffin-Valade,
I appreciate the opportunity to review and respond to the draft report and recommendations from
the OIR Group regarding the 2006 Chasse investigations. The tragic death of James Chasse on
September 17, 2006 has had a profound impact on the City of Portland, including all of us in the
Portland Police Bureau. In the past four years, we have made many changes to our policies,
procedures, and the training we provide to our officers and supervisors. We have made changes,
not only in the way we investigate use of deadly force and in-custody deaths, but have worked to
improve the process in which we review these events. As a progressive organization, we
welcome input and recommendations from all sources with the goal of identifying all areas
where we can improve and work more closely with the community.
I would like to thank OIR Group for their thorough and professional review of our investigation.
They have appropriately taken into account and acknowledged those changes we have made over
the past several years and provided us with thoughtful and constructive recommendations. We
agree with the vast majority of these recommendations, some of which have already been
implemented. For the few where we have concern, we are committed to thoroughly reviewing
them with an open mind, conducting further research and finding the practice that will work best
in the City of Portland.

Community Policing: Making the Difference Together
An Equal Opportunity Employer
City Information Line: 503-823-4000, TrY (for hearing and speech impaired): 503-823-6868 Website: www.portlandpolice.com

Ms LaVonne Griffin-Valade

OIR Review
July 22, 2010

I am pleased, even though their comments and recommendations are based on the review of this
one investigation, that the OIR Group has recognized the Portland Police Bureau as being, “head
and shoulders above most comparable agencies with regard to the way in which it investigates
critical incidents.” We, like OIR, believe there will always be room for improvement.
The Portland Police Bureau is an excellent organization, full of talented, hard working
professionals who are dedicated to serving the citizens of Portland. We are committed to being
transparent and not only willing to self critique in order to make change, but willing to accept
outside input in order to grow and improve as a police agency. I look forward to working with
you, Director Baptista, and all of your staff in all future reviews and assessments of the work we
do for the City of Portland.

Sincerely,

MICHAEL REESE
Chief of Police

Recommendation #1
The Bureau should consider adopting internal protocols for in-custody death investigations that
recognize the advantage of on-scene face-to-face interviews for civilian eyewitnesses and the
need to conduct those interviews shortly after the incident has occurred if practicable. If
conducting such interviews immediately after the event is not practicable, that fact should be
noted in the investigative file. Agree. This is the current practice in the Homicide detail. We
agree that more can be done to ensure that better documentation is done when deviations are
made. We are going to incorporate this into the Detective Division SOP.
Recommendation #2
The Bureau should consider revising internal investigative protocols so that the transport of
officers from the scene is documented. Agree and this is also the current practice with the
Homicide detail that should be better documented.

Recommendation #3
The Bureau should consider initiating discussions with the union to reform protocols so that
involved personnel can be interviewed about their actions contemporaneous with the incident.
Agree. This is something that has been ongoing for years and we are again looking at several
options for getting quicker interviews. We will be working with the District Attorney, IPR and the
Unions to improve our process.

Recommendation #4
The Bureau and the City should consider initiating dialogue with AMR to develop protocols
ensuring future cooperation of the private ambulance company in PPB in-custody death
investigations. We agree with this concept and will be looking at several options to ensure better
cooperation.

Recommendation #5
The Bureau should consider adding representatives of the Training Division and Internal Affairs
Division to their in-custody death scene response. This has been tried in the past in response to
the PARC review, our initial experience was not found to be productive for a variety of reasons.
We are going to revisit this issue and determine if this can be done in a more useful manner.

Recommendation #6
The Bureau should consider creating an internal policy that would set a realistic but certain
deadline by which the Detectives’ notebook must be presented to IAD. Divergences from such
an internal policy should be based on good cause and only after obtaining written approval at the
Assistant Chief level. We agree but also realize that each case presents different challenges and
we will be attempting to balance the need for complete and thorough investigation with the need
for quick resolution. Requiring A/C approval will ensure accountability.

Recommendation #7
The Bureau should consider drafting internal policies recognizing the critical importance of a
robust IAD function and ensuring that resources not be diverted away from this unit. Agree with
the concept. We will research and consider if internal policy is the best place to document this.
This particular case caught us in transition from having sworn investigators to non-sworn
investigators. We are committed to this and we were able to preserve our non-sworn
investigators during the last budget process.

Recommendation #8
In critical incident investigations where outside government agencies place roadblocks on access
to information or witnesses, PPB should consider enlisting the assistance of its Commissioner
and/or City Council to help remove those roadblocks. Agree.

Recommendation #9
In critical incident investigations where outside entities successfully prevent timely access to
important witnesses, the PPB should consider the evidence already obtained from the witness,
the potential value in obtaining delayed information from the witness(es) in question, and
determine whether the IAD investigation should proceed without the additional information.
Agree.

Recommendation #10
In shootings and in-custody deaths involving members of outside law enforcement agencies as
either participants or witnesses, Detectives should be instructed and trained to question these
individuals regarding administrative issues when they interview those outside members, on the
assumption that IAD may not be able to timely interview them. Agree. We will be looking at the
combined effort of IAD and Detectives.

Recommendation #11
The Bureau should consider requesting the Training Division devise protocols to ensure that
equipment issues are addressed in their analysis. With particular respect to breathing guards, we
recommend that the Bureau consider whether it should ensure that each patrol car is outfitted
with such a device. Agree and this is current practice. Each car is now outfitted with breathing
guards, and they are listed on the inspection checklist.

Recommendation #12
In cases where tactical decision making may have resulted from a lapse of supervision, the
Bureau should encourage rather than limit IAD to develop these issues in its investigation.
Agree and this is current practice.

Recommendation #13
The Bureau should consider modifying Use of Force Review Board protocols so that in cases in
which new evidence is developed and considered by the Use of Force Review Board, the
Training Division should be contacted to determine whether a supplemental analysis and
presentation to the Board is warranted. Agree.

Recommendation #14
The Bureau should consider revising its protocols so that all UFRB members are notified of the
final outcomes of the cases in which they participate. Agree.

Recommendation #15
The Bureau should consider making available during the UFRB additional copies of the
investigative materials so that all Board members can readily access a given transcript or
diagram during the meeting. Agree and this is the current practice.

Recommendation #16
The Bureau should reconsider the advisability of encouraging the involved officer to appear
before the UFRB. The Bureau will look at this and this issue may be addressed by the structure
of the new board. The new facilitator will be able to control the content of information provided
by the officer limiting the information to clarifying information and not mitigating information.

Recommendation #17
The Bureau should consider refinements to the Emergency Medical Custody Transport Directive
to more clearly define PPB officers’ responsibilities. Agree. This has been done and is the
current practice.

Recommendation #18
Consistent with its revised Tactical Doctrine, the Bureau should consider revising its foot pursuit
policy to include additional factors officers should weigh in deciding whether to initiate or
continue a foot pursuit. Agree and this is our current practice.

Recommendation #19
In the interest of transparency, the Bureau should consider whether a portion of its CIT training
could occasionally be opened and training materials made available to interested members of the
public. Agree except where disclosure of those portions that would negatively impact public and
officer safety.

Recommendation #20
The Bureau should consider whether the circumstances surrounding the Chasse case can be
developed into a training video for the benefit of all Bureau members. Agree. We have done
some training videos related to specific portions of this event. We are looking at preparing an
overall video covering this incident.

Recommendation #21
The foot pursuit data collection and tracking initiative should continue to be supported by the
Bureau and the data developed from the initiative should be periodically made available to the
public. Agree. The information is continuing to be collected and, under the new ordinance, is
available through IPR

Recommendation #22
The Bureau should consider devising a Directive requiring any sergeant or lieutenant involved in
a significant use of force incident, where practical, to relinquish his or her role as supervisor once
the force incident is over and call for another supervisor to respond to the scene and assume
command of the response to the incident. Any supervisor who responds to an incident in which
another supervisor has been involved also should have a concomitant duty to assume command
and relieve the involved sergeant or lieutenant of his or her on scene responsibilities. Agree and
this is the current practice.

Recommendation #23
The Bureau should consider revising its policies and training to prohibit officers’ transport of
subjects in maximum restraints. It should also review its policy and training on carrying subjects
in maximum restraints, explore alternative methods for moving subjects, and modifying its
training doctrines accordingly so that officers are at least instructed to minimize the distance they
carry subjects in maximum restraints. Agree. The Bureau made a training video in July 07which
covered maximum restraint application. The Training Division will be reviewing our practice in
this area.

Recommendation #24
The Bureau should consider adopting a policy of not hiring lateral candidates from other law
enforcement agencies while they are the subjects of pending administrative investigations.
Agree when the allegations are of serious misconduct.

Recommendation #25
The Bureau should consider extending its draft a policy requiring members directly involved in
fatal shootings be placed in administrative assignments for at least one month following the
Grand Jury, subject to month-to-month review by the members division commander and
Assistant Chief to officers involved in in-custody deaths as well. Agree. This was already
incorporated into a later draft of the policy.

Recommendation #26
The Bureau should consider initiating a dialogue with TriMet and participating agencies to forge
an agreement that participating agencies will ensure complete and timely cooperation of their
personnel, including an agreement to be promptly interviewed in any subsequent PPB criminal or
Internal Affairs Division investigation. Any agreement should include specific language that
ongoing civil litigation should not be a reason for refusing to provide PPB timely access to these
individuals. Agree and this is in progress. We are working on a pilot project where agencies
conduct a joint investigation.

Recommendation #27
The Bureau should consider the potential challenges, coordination, and uniformity issues
presented by the multi-jurisdictional nature of the Transit Division and work with its
counterparts to ensure all Transit officers have been trained in and will be held accountable to a
set of core policies and key tactical training doctrines to better ensure that when officers are
presented with dynamic events, there is a pre-existing, coordinated, and consistent understanding
of how each participant will respond to that event. Agree in concept and will research options.
The Chief and the Commander of the Transit Division will be working with the chiefs of all
involved agencies to achieve this.

OIR

GROUP

OIR Group provides consultant services to law enforcement agencies for officer-involved
shootings, use of force incidents, investigative protocols, force policies, procedures, and training,
as well as all forms of alleged police misconduct. Additionally, in response to requests from the
Los Angeles County Sheriff’s Department and other law enforcement agencies, OIR Group
attorneys have provided training on investigations and direct feedback to field supervisors and
internal affairs investigators.
Since 2001, attorneys with OIR Group have contracted with Los Angeles County to provide
independent civilian oversight for all internal affairs and internal criminal investigations
functions within the Los Angeles County Sheriff’s Department, the largest sheriff’s department
in the nation. In this capacity, these attorneys have been known as the Office of Independent
Review (“OIR”). Specifically, within the last eight years, OIR has reviewed high-profile officer
involved shootings, inmate murders in county jails, and scores of less-than-lethal force incidents
on patrol, in the jails, and in the courts. A vital part of the OIR’s review is to ensure thorough
and objective investigations into these critical incidents. For each officer-involved shooting,
death in custody, and major force incident, OIR is mandated to assess the quality of the
completed investigation and where lacking, provide feedback designed to ensure that the
investigation is thorough. When investigations fall short of minimal standards, OIR has issued
public reports highlighting those shortcomings and the potential impact on credibility with the
public as well as risk management implications.

Michael Gennaco is a founding member and Chief Attorney of the Office of Independent
Review. Mr. Gennaco has also been appointed by a federal judge as an expert consultant to
assist in designing an independent review agency for the California Department of Corrections
and Rehabilitation. Mr. Gennaco has also assisted other law enforcement entities, including the
San Diego County Sheriff’s Department, Oakland Police Department, Inglewood Police
Department, Pasadena Police Department, Torrance Police Department and Palo Alto Police
Department regarding review of officer-involved shootings, force, internal affairs and oversight
matters.
Mr. Gennaco served for over six years as an Assistant United States Attorney for the Central
District of California. As Chief of the Civil Rights Section, he was responsible for overseeing all
investigations and allegations of federal civil rights violations. Prior to that, Mr. Gennaco was a
federal prosecutor for eight years for the Criminal Section of the United States Department of
Justice Civil Rights Division. Mr. Gennaco is a graduate of Dartmouth College and received his
JD from Stanford Law School.

Robert Miller is Deputy Chief Attorney of Los Angeles County’s Office of Independent Review
and a founding member of OIR Group. He graduated from Stanford University and UCLA
School of Law. He came to the OIR from a fifteen-year career in the Los Angeles County
District Attorney’s Office where he prosecuted murders, other violent felonies and white collar
cases, in particular environmental crimes. His independent oversight duties for Los Angeles
County include review of officer-involved shootings as well as misconduct cases at Sheriff’s
patrol stations and the central jail. He has authored special reports on topics ranging from
alcohol-related misconduct to inmate-on-inmate murder. Mr. Miller has participated in a number
of recent OIR Group projects for a wide variety of cities and law enforcement agencies focused
on officer-involved shooting investigations, use of force investigations and other critical
incidents.

Julie Ruhlin joined OIR after working as a consultant with the Police Assessment Resource
Center in Los Angeles, where she worked on police policy and training and issues. Her primary
responsibilities at OIR involve monitoring issues surrounding the county jails, including uses of
force, allegations of deputy misconduct, and inmate deaths. Ms. Ruhlin also has reviewed
numerous officer-involved shootings and other critical incidents in her work with the Los
Angeles County Sheriff’s Department. She has served as a court-appointed expert to assist in
design of an internal civilian oversight entity for misconduct investigations in the California
prison system. She came to her career in police oversight from a private law practice in criminal
defense and civil rights litigation. She also served as a law clerk to the Hon. Christina A. Snyder
of the United States District Court. She graduated from American University and the University
of Southern California School of Law.