Prosecutors in Florida have announced they will not be bringing charges against four prison guards who held a black, schizophrenic prison inmate in a hot shower for hours.
The memo, released on Friday by the office of the Miami-Dade State Attorney Katherine Fernandez Rundle, concluded Darren Rainey had died in part because of undiagnosed heart disease and suffered no scalding injuries.
It ends a nearly five-year probe into the death of the 50-year-old at the Dale Correctional Institution where he was serving a two-year sentence on a cocaine charge.
Rainey was taken to the shower on 23 June 2012 after he had smeared faeces on himself, the walls of his cell and his bedsheets, according to the memo written by Assistant State Attorneys Kathleen Hoague and Johnette Hardiman.
The shower, which was operated from an adjoining room by a corrections officer to prevent inmates from turning it off, was activated but Rainey refused to stand under the water, according to the memo.
Officer Roland Clarke told Rainey he couldn't go back to his cell until he washed off. Finally, Rainey said he would comply and asked for soap, which he was given, the memo says.
After starting to wash, Rainey said, "No, I don't want to do this," and leaned on a wall away from the water, Officer Clarke told investigators.
Officers continued to check on him, and finally after about two hours the decision was made to take Rainey out of the shower, but he was found lying face up in about 3 inches (8 centimetres) of water with no pulse and not breathing.
But the memo rejected claims made by another inmate, Harold Hempstead, that he had heard Rainey yelling and kicking at the shower door, saying "I'm sorry. I won't do it anymore" and "I can't take it no more" and hearing the guards laughing.
Ms Hoague and Ms Hardiman concluded Hempstead was an unreliable witness and cited contradictions with testimonies by other inmates.
It echoed the findings of Dr Emma Lew, Miami-Dade’s medical examiner, who said Rainey did not suffer any burns of any kind and there was no evidence of trauma.
She attributed his death to a combination of his schizophrenia, heart disease and confinement in the small shower space.
She said schizophrenic people can have nervous system reactions that trigger a heart attack if they have an underlying condition.
Several witnesses said Rainey's skin appeared to be peeled back or reddish in some spots — one inmate claimed he looked like a "boiled lobster" — but an autopsy found this "slippage" was most likely caused by friction or pressure on his moist and warm skin.
This could have happened during efforts to revive him, such as chest compressions, or when officers carried him out of the shower initially, the memo said.
But a nurse told the Miami Herald shortly after his death that Rainey’s body temperature that night was so high it could not be read on a thermometer and a report written the day of the autopsy referred to “visible trauma...throughout the decedent’s body”.
Police, who began to examine the case in 2014 after an investigation by the newspaper, interviewed 26 inmates of the mental health ward of the prison, known as the transition care unit (TCU), at the time of Rainey’s death.
Six of those interviewed said the officers used the showers to punish inmates when they misbehaved by holding them in there and turn the water to scalding and freezing.
Three said they had been subjected to this treatment themselves, six said they had had no problem with the showers and 14 were too ill to say anything credible or refused to talk altogether.
The lawyer acting for Rainey's family, Milton Grimes, said in a statement that the family is "disappointed and heartbroken" no charges will be brought.
"This is not justice for Darren, for his family, nor for the mentally ill who have been subject to similar abuse and mistreatment," Mr Grimes said.
The prosecutors determined that corrections officers did not commit murder or manslaughter in Rainey's death and that taking him to the shower was appropriate under the circumstances.
"Placing an inmate who has defecated upon himself in a shower to decontaminate himself is not conduct that is criminally reckless," they wrote. "There was no evidence of any intent to harm Rainey."
Additional reporting by AP