A Ventura County coroner's report released Monday sharply contradicts the Ventura Police Department's version of events preceding the death last month of a 24-year-old psychiatric patient who was shocked repeatedly with electric stun guns.
Police said Duane Johnson of Oxnard was jolted four times with the weapons before his death. But, according to the coroner's report, two mental-health workers told county investigators that stun guns were used from seven to 11 times on the man during the 45 minutes before his death.
The workers, who witnessed the incident, maintained that officers shocked Johnson at least six times with a stun gun after they gained control of him in his hospital room Feb. 13, according to the report by coroner's investigators.
The workers complained that the patient, tethered face-down on a gurney, was unnecessarily shocked with the weapons as officers moved him from his room at Ventura County Medical Center to a county psychiatric facility nearby.
Johnson, who was in the hospital because of a near-fatal heart attack two weeks before his death, was "restrained and not a threat to himself or others," one worker told investigators.
Officers continued to apply a stun gun to Johnson because he ignored their commands not to grab for hospital workers who were accompanying him to the mental facility, the workers said.
Police have maintained that Johnson, a muscular former athlete, was shocked once with a small Nova stun gun by Officer Lynn Klamser and three times with a larger Taser weapon by Sgt. George Morris.
Both weapons fire electrical charges of about 50,000 volts, which police say is similar to a jolt received when an automobile spark plug wire is touched.
The weapons were used, police said, to force the patient to release his grip on a glass medical instrument during the initial struggle in the hospital room and, a few minutes later, to force him to release a hospital worker's leg. Johnson's hands were handcuffed to the gurney railing, but he was able to move his arms parallel to the rails.
The Taser was applied twice more when Johnson refused to be handcuffed while being moved from the gurney into an isolation room, police said. He died about 45 minutes after the incident began and at least five minutes after the final Taser jolt, police said.
Officers using the stun guns were unaware of Johnson's heart problems, police Lt. Michael J. Tracy said Monday.
"We stand by the account we made previously," Tracy said, responding to the coroner's report. "We've completed our investigation and sent it to the district attorney, and now it's up to him to review various reports and do what's appropriate."
The district attorney's office has refused to comment on the case until its investigation is concluded.
The Police Department, after an investigation by homicide detectives, cleared the four officers in the Johnson incident, Tracy said. Hospital and mental-health employees interviewed by police supported the officers' version of events, he said.
Department policy allows officers to use stun guns--which are considered a non-lethal alternative to nightsticks and firearms--to control people who pose a threat to officers or to the public. They also can be used to force crime suspects to comply with officers' instructions.
County Coroner F. Warren Lovell said he had not yet determined whether shocks from the stun guns were the cause of Johnson's death, or if they contributed to it.
"This case is going to be a tough call," the coroner said. "This man had so many other things wrong with him."
Johnson had chronic heart disease and probably would have died Jan. 28 of a severe cardiac arrhythmia, or irregular heartbeat, had he not already been a patient at the mental-health facility, about 300 feet from the medical center's emergency room, Lovell said.
Johnson's "fighting and struggling" during the incident two weeks later put additional stress on his heart, the coroner said.
But, according to the coroner's investigative report, at least one police officer may have applied the stun weapons to Johnson in durations longer than the one- to two-second bursts reported by police. Departmental policy calls for such short applications.
One mental-health worker, Ferris D. Grubb, told investigators that when officers transferred Johnson to the isolation room, one held a Taser to his shoulder blades "the entire time" it took to bring his rigid arms from his side to behind his back for handcuffing, according to the report.
"Mr. Grubb did not feel this was necessary and told the officers. . . . They did not respond," coroner's investigator Dale E. Zentzis said in the report.
Lt. Tracy agreed that Morris kept the Taser on Johnson's back during the handcuffing, but said he took his finger off the trigger after two separate bursts of one or two seconds.
Wayne Flick, the second health worker, also said he thought the officers' repeated use of the Taser was unnecessary, Zentzis said.
Lovell said that "prolonged application of the Taser would certainly contribute to the problem. The question now is how much did he get. . . . That's crucial." But, with the contradictory accounts, "I don't know if we're ever going to know the truth," he said.
Johnson's death is the second in three years in Ventura County that has followed the use of stun guns by police officers.
In 1987, Lovell found that jolts from a small Nova stun gun contributed to the death of a Port Hueneme man who died of heart failure while intoxicated with cocaine. Police had been called when the man barricaded himself in his bedroom with his girlfriend's two children.
The district attorney's office found that the officers had acted according to their training and violated no law.