From the moment Los Angeles police handcuffed him, Jorge Azucena told officers he needed help.
"I can't breathe, I can't breathe," he pleaded. "I have asthma, I have asthma."
In the half-hour or so after his arrest late one night last September, Azucena said over and over that he was struggling for breath. Numerous LAPD officers and sergeants heard his pleas for medical attention but ignored them even as his condition visibly worsened.
"You can breathe just fine," one sergeant told him. "You can talk, so you can breathe."
Azucena could not walk or stand by the time officers brought him to a South Los Angeles police station for booking. So they carried him into a cell, leaving him lying face-down on the floor. He was soon unconscious. When paramedics arrived shortly after, Azucena's heart had stopped.
The chilling account of how Azucena died is told in two reports made public this week. After a Times article last year on the circumstances surrounding Azucena's death, the reports offer new details into the man's desperate and futile attempts to convince officers his lungs were succumbing to what coroner's officials determined was most likely an asthma attack.
Nearly a year after Azucena's death, LAPD officials have not yet determined whether any of the officers involved that night should be disciplined for failing to summon help and, in the case of some officers, for lying to investigators. Nine officers and two sergeants are the subjects of ongoing internal investigations, while another sergeant under scrutiny recently retired, said Capt. Paul Snell, who commands the LAPD's Southwest Division, where the death occurred. As is customary, prosecutors from the county district attorney's office are reviewing the case to determine whether the inaction amounts to criminal behavior.
"There should not be any question that when somebody in custody is heard to say 'I cannot breathe,' the officers should promptly call for an ambulance," said Robert Saltzman, a member of the Police Commission that oversees the LAPD.
Through a spokesman, LAPD Chief Charlie Beck declined to comment.
One of the reports was forwarded by Beck to the Police Commission. The other was written by the commission's inspector general, who conducted an independent investigation.
Investigators were able to piece together much of what occurred the night of Azucena's death with recordings made by cameras the department installed several years ago in cars used to patrol South Los Angeles neighborhoods. The department has recently come in for criticism for slow adoption of a plan to outfit vehicles with cameras in the rest of the city. The department's South Bureau is the only one of four that has such equipment.
About 11:20 p.m. on Sept. 6, Azucena led police on a brief chase after running a red light, Beck wrote in the department report. The names of officers were redacted in a copy of the report provided to The Times under the public records act. The inspector general's report did not identify the officers by name.
According to Beck's report, the pursuit went on for a few miles, until Azucena stopped on the edge of a park and he and his two companions ran off.
Azucena was cornered quickly in a nearby apartment complex and gave himself up. Microphones worn by several officers at the scene captured Azucena complying with their commands to lie on the ground and telling them, "I can't breathe."
Minutes later, as he was lying handcuffed on the ground, Azucena said again that he was struggling to breathe and told the officers he had asthma. Officers had to help him to his feet and hold him by the arms as he walked to a patrol car. One officer recalled to investigators that Azucena was "walking wobbly" and seemed "fatigued," Beck's report said.
Over the next 10 minutes, as various officers and sergeants watched over him, Azucena is heard on the recordings complaining about his trouble breathing at least five times, the reports showed. In one exchange, he told officers he was on drugs and believed he was having a seizure. At another point, he began yelling to onlookers.
"Help me, help me, help me," he shouted, according to the inspector general's report. "I can't breathe. I can't breathe. Help me, please."
In response, a sergeant ordered officers to place him in the back seat of a patrol car, believing he was trying to incite the crowd watching, the report said.
The patrol car's camera recorded Azucena as he tried to lie down in the back seat. When an officer ordered him to sit up, Azucena kicked the car door and said, "I can't breathe. Help me, help me. I can't breathe," according to the reports.
Several officers and sergeants told investigators afterward they did not see any indications that Azucena was in serious distress. One recalled that Azucena seemed to be trying to catch his breath as he sat in the patrol car waiting to be brought to the station but nonetheless appeared to be fine.
The inspector general's report highlights several exchanges in which police dismiss Azucena's complaints and tell him that he is fine because he is talking. Several officers told investigators they noticed that Azucena was sweating but believed the humid weather and his attempt to flee were responsible, the report said.
Steve Soboroff, president of the civilian commission that oversees the LAPD, declined to discuss the specifics of the case but said it was "troubling" that so many officers ignored Azucena. The case, he said, underscored the need to better train officers on department policies that require them to call for an ambulance whenever a suspect complains of breathing problems.
"I don't think this points to a culture of officers who don't care about people," Soboroff said. "But it's important that we make sure officers know they can follow their own moral compass and can feel comfortable speaking up in any situation if they have questions about what is going on."
Azucena continued to plead with officers during the ride to the station, and one lowered a window for him.
When they arrived at the station, Azucena collapsed to his knees as he tried to get out of the patrol car, according to the reports. One officer told him "that he needed to act like a man and walk," according to the inspector general's report.
Hoisting him up, the officers brought Azucena inside, with his feet dragging behind him, and laid him on the floor outside the office of a sergeant who was working as the station supervisor. Again, recordings picked up Azucena saying he could not breathe, the reports said.
Whenever someone is taken into custody and brought to a station, LAPD rules require that the station's supervisor ask a series of questions before the suspect is placed in a detention cell.
One of the questions that must be asked and documented on a form is whether the person is ill or has any medical conditions needing attention.
According to the inspector general's report, the supervisor told investigators that he did ask Azucena if he was sick or injured and recorded his answer as "not responsive" on the form.
The two officers who brought in Azucena carried him into one of the station's holding cells, leaving him face-down on the floor. A short time later, another officer noticed that Azucena appeared to be in distress, the reports said. Shortly after, officers noticed that he appeared not to be breathing. Nearly 40 minutes after Azucena was taken into custody, paramedics arrived and tried to revive him before taking him to a hospital. Doctors there tried for a few more hours before declaring him dead.
Although blood tests revealed methamphetamine in Azucena's system, county coroner's officials concluded from an autopsy that asthma probably killed him. They classified the death as an accident.