Independent Monitor, Nicholas E.
Independent Monitor Releases Report
Regarding the Death of Michael
Colorado – (March
19, 2018) Today, the Office of the Independent
Monitor (“OIM”) released a report entitled The Death of Michael
Marshall, an Independent Review. On November
11, 2015, Michael Marshall, a mentally ill man, was being held in
the custody of the Denver Sheriff Department (“DSD”) on a $100
bond. When Mr. Marshall attempted to enter a jail hallway
without permission, deputies used force to restrain him while he
intermittently struggled on the floor. Mr. Marshall
eventually lost consciousness and deputies tried to resuscitate him
with CPR. He died nine days later, and his cause of death was
determined to be, among other things, positional asphyxia due to
restraint by law enforcement. Following the incident, an
internal investigation was conducted by DSD’s Internal Affairs
Bureau (“IAB”), which resulted in short suspensions being imposed
on two deputies and a captain. In 2017, the City and County
of Denver (“City”) settled potential civil claims related to this
incident with a $4.65 million payment to Mr. Marshall’s family, and
an agreement to make certain policy and training changes in the
The OIM is made up of attorneys, investigators, and criminologists
who provide oversight of the DSD. OIM staff responded to this
incident immediately after it happened, and monitored the IAB
investigation. The report analyzes the incident, IAB
investigation, and disciplinary decisions, and makes several key
- The City and the
DSD made commendable improvements after Mr. Marshall’s death,
including re-engineering the DSD’s Use of Force and Use of
Restraints Policies, and committing to providing additional
mental health services for inmates.
- IAB is mandated to
conduct thorough and impartial investigations. Yet it
attempted to summarily close its investigation, finding no
violations of policy, without interviewing the subject
deputies, questioning the involved nurses, or obtaining other
information necessary to completely and impartially evaluate
the use of force that was one of the causes of Mr. Marshall’s
death. The OIM had to intervene on multiple occasions to
ensure an investigation that complied with the minimum
investigative standards contained in DSD policy.
- Despite national
best practices regarding background checks for law enforcement
recruits, the Department of Safety (“DOS”) permitted an
involved deputy to join the Denver Police Department as a
police recruit while he was a subject of the criminal
investigation into the use of force against Mr. Marshall, and
before there had been any internal investigation into his
conduct. There is no official finding regarding the
allegations against him to this day.
- Finally, almost
three years after outside consultants recommended that the DSD
develop a formal protocol for analyzing all significant uses
of force in Denver’s jails in order to learn from them and to
prevent their recurrence, the DSD has to yet to fully implement
such a process.
includes eight actionable recommendations to the DSD and DOS to
address these and other findings discussed in the report.
“This incident was a tragedy for Mr. Marshall, his family, and for
the public,” said Independent Monitor Nicholas E. Mitchell.
“As a city, we have an obligation to learn from it, and I hope that
the DSD and DOS use this report to make quick and effective changes
to prevent future tragedies in our jails.” The full report
can be found at www.denvergov.org/oim.