MANSFIELD, Ohio — The special prosecutor investigating the death of 28-year-old Alexander Jose Rios after an incident inside Richland County Jail said he has asked an independent medical expert to review an autopsy and coroner's report concluding Rios died from the controversial syndrome known as excited delirium.
"I question how they arrived at that conclusion,” said Medina Co. Prosecutor Forrest Thompson.
Richland County Prosecutor Gary Bishop asked Thompson to determine whether officers involved in Rios’ death should face criminal charges.
Video shows the officers punched, tasered and stepped on Alex's back while failing to recognize he was in serious medical distress.
GRAPHIC CONTENT WARNING: Rios was sent to the Richland County Jail on a drug-related warrant. What led to his death was caught on camera. We want to warn you – what you are going to see is graphic. We know this is difficult to watch. However, ultimately, we believe it’s important to show you the critical moments that explain how he died, and the Rios family wants you to see this video too, because they want answers.
RELATED: A Fatal Five Minutes - Man's family demands answers after Richland jail video shows critical moments before his death
"In my review, it appears that excited delirium is something that oftentimes gets used when there’s law enforcement involvement and that has no other explained origins. And I believe that this case fits that protocol," Thompson said.
The coroner's conclusions
Richland County Coroner Daniel Burwell concluded Rio's cause of death was excited delirium. Burwell listed the manner of death as accidental.
The report notes Rios' hospital drug screen was positive for amphetamines.
Burwell declined News 5's requests for an on-camera interview.
Rios' autopsy was performed by Dr. Lee Lehman, a forensic pathologist at the Montgomery Co. Coroner's Office.
During a phone conversation, when 5 On Your Side Investigator Sarah Buduson asked how he determined Rios died from excited delirium, Dr. Lehman hung up.
Montgomery Co. Coroner Kent Harshbarger also declined News 5's interview request citing "pending legal considerations."
View the complete Richland County Coroner's report below:
Alexander Rios - Coroner's Report by Wews WebStaff on Scribd
What is excited delirium?
The American College of Emergency Physicians said excited delirium "refers to a condition in which a patient is delirious, and they have a dangerously high temperature, high pulse, and high blood pressure, and can exhibit ‘superhuman’ strength. Excited delirium is caused by an extreme overload of adrenaline—which we often see in patients who have used illicit drugs such as K2, bath salts, and meth."
Police officers mentioned excited delirium in the deaths of George Floyd in Minneapolis and Elijah McClain in Aurora, Colorado.
In the video of George Floyd, Officer Thomas Lane asks Officer Derek Chauvin if they should turn Floyd on his side.
"I'm just worried about excited delirium or whatever," Lane said.
In McClain's case, an Aurora Fire Department report said “he was suffering from possible excited delirium.”
Unlike in Rios's case, excited delirium was not determined to have caused their deaths.
'The story doesn't fit'
Despite ACEP's recognition of excited delirium, News 5 found many medical organizations and experts do not recognize excited delirium as a valid diagnosis.
It is not recognized by the American Medical Association, the National Association of Medical Examiners, the American Psychiatric Association, or the DSM-5, which is the APA's diagnostic tool used by U.S. mental health professionals.
"The fact that it’s (excited delirium) not in there says it’s not been rigorously tested and it’s not been rigorously validated," said Dr. Debra Pinals, Chair of the American Psychiatric Association’s Council on Psychiatry and the Law. Dr. Pinals is also the director of the Program in Psychiatry, Law, and Ethics and a clinical professor of psychiatry at the University of Michigan Medical School.
“If this is to be considered a true diagnosis, where’s the research and where’s the data to support its validity?" Dr. Pinals said.
She said delirium is a recognized condition, but the symptoms associated with excited delirium, including being "impervious to pain," excessive strength, and agitated interactions with law enforcement don't add up.
"The story doesn’t fit what would be medically logical for somebody with any kind of delirium," Dr. Pinals said. "The use of the term excited delirium concerns me, in context of law enforcement, especially because very often what I have seen is that it’s used as an explanation after a death occurs."
'A wastebasket diagnosis'
"Excited delirium, that specific diagnosis, we have to really emphasize how it’s a wastebasket diagnosis," said Dr. Altaf Saadi, a neurologist at Harvard Medical School and Massachusetts General Hospital.
"It hides behind medical terminology to make it seem legitimate on the surface when, in reality, it’s not," she said.
Dr. Saadi and two colleagues wrote an editorial in The Washington Post describing excited delirium as 'junk science' used as a "diagnosis" to "shield officers from accountability."
Dr. Saadi said there is "no set criteria" and "no anatomic basis or pathological basis" for excited delirium. Instead, the term "conflates a bunch of different diagnoses" involving drug use and mental health.
"I would not be relying on this as a justification for people’s death," Dr. Saadi said.
How it started
The term excited delirium was first used by researchers in the 1980s to describe the deaths of crack cocaine users in police custody.
Excited Delirium (ExDS) was given credibility by the American College of Emergency Physicians (ACEP) and an ACEP task force's 2009 white paper on the topic.
White Paper Report on Excited Delirium Syndrome (ACEP) by Wews WebStaff on Scribd
The paper said excited delirium is a 'real syndrome' that often leads to death.
However, the paper acknowledges there is "a lack of a clear definition and cause."
Dr. Saadi said many of the paper's authors have ties to law enforcement and to Axon Medical, which manufactures the Taser stun gun.
"There’s a lot of bias and conflict of interest in terms of what’s out there about this diagnosis," Dr. Saadi said.
For example, Dr. Jeffrey Ho, who signed the white paper, is also a licensed deputy sheriff in the state of Minnesota and currently serves with the Meeker County Sheriff’s Office, according to biographer on the Hennepin Healthcare website.
In an email to News 5, ACEP Senior Public Relations Manager Steven Arnoff sent the following statement:
"Patients with excited delirium can often become violent and can cause harm to themselves and others. The adrenaline release can cause serious damage to the patient. Medical experts believe sudden death can occur in patients with excited delirium due to cardiac damage from the huge surge of adrenaline, the very high temperatures and release of large amounts of lactic acid. Patients are often extremely agitated and aggressive, and they can suddenly become calm for a few minutes before their heart stops and they die. Multiple studies note that, left untreated, the death rate from excited delirium may be in excess of 10 percent.
While the term ‘excited delirium’ is not yet universally accepted in the medical community, as certain specialists may not have seen patients in this extreme state, emergency physicians can attest firsthand to the condition and its potentially life-threatening impact on patients.
In 2009, the American College of Emergency Physicians (ACEP) had a taskforce which produced an information paper that acknowledged excited delirium as a real condition, and discussed its impact on patients’ health, including mortality rate. The 2009 information paper was not officially endorsed by ACEP and the body of literature around excited delirium and the use of Ketamine has grown significantly since its publication.
In 2020, ACEP formed a new workgroup to deepen the understanding around the best treatment for excited delirium given the expanded knowledge base since that paper was originally published. This group of emergency physicians, EMS physicians, pharmacists, toxicologists, anesthesiologists, nurses and patient safety experts are currently evaluating the literature and research on excited delirium developed since 2009 to make recommendations for the use of ketamine in prehospital settings.”
'It matters to us'
Alex's family has been demanding answers since his death 18 months ago.
"It just seems like it doesn't matter to anybody," said Don Mould, Rios's stepfather. "It matters to us."
Rios was booked into the Richland Co. Jail during the early morning hours of Sept. 19, 2019 on an outstanding drug-related warrant.
Less than 24 hours later, he was on life support.
Alex's family only learned about the critical moments before his death last December when Richland County released the video.
Adam Rios, Alex's older brother, works in corrections. After watching five corrections officers restrain, taser, punch, and step on his little brother, he said it is clear the officers' actions contributed to his brother's death.
"Was his noncompliance a death sentence?" he said. "Was it worth the death sentence? It wasn’t. Just because somebody does something you don’t agree with doesn’t mean they should die for it."
“They threw his body in a corner and let it slump over like he was nothing," said Adam's wife, Hillary Rios.
“It’s very clear on that video when he’s in distress. And they didn’t care," she said.
The family said they struggle to explain how Alex died to his sons, Marcus, 12, and Anthony, 6.
"It bothers me that it’s okay to treat somebody like that," said Mould. "Not just our son. Anybody."
Rios' family is considering filing a civil rights lawsuit over his death.
Richland County and Montgomery County coroner’s offices: 2 - Attempted to comply, but failed to provide information in a reasonable time frame
Both the Richland County Coroner and a forensic pathologist from Montgomery County assigned to this case declined an on-camera interview, and the pathologist from Montgomery County hung up during a phone conversation when asked about the conclusion in the coroner’s report. The Montgomery County Coroner declined an interview citing “pending legal considerations,” even though no litigation has been filed on behalf of the family at this time.