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A 22-year-old man dies in Milwaukee police custody after officers fail to get him urgent medical attention. An internal investigation finds police did nothing wrong, despite cuts and bruises all over the man's body. The community is outraged. The department promises training and changes to the system.

Thirty years ago, that sequence of events described the death of Ernest Lacy. Today, the same set of circumstances applies to the July 2011 death of Derek Williams. Police chiefs, city leaders and state lawmakers have promised new laws, tougher policies and better training following Lacy's death and others like it over the past three decades. The same assurances are being made in the wake of Williams' death.

But time and again, the department - from commanders to front-line officers - reverts to its old ways once the spotlight fades, a Journal Sentinel investigation found.

Then someone else dies and the same reforms are proposed again:

• Since 1983, it has been a crime for police to fail to render aid to a prisoner. A long-standing department policy requires officers to monitor prisoners' medical conditions and call paramedics if necessary. Last month, amid the public outcry over Williams' death, Chief Edward Flynn issued a directive that takes away officers' discretion and requires them to do what they had already been taught: Call for help if someone in custody is having trouble breathing, bleeding profusely or experiencing moderate to severe pain.
• In 1992, authorities created a review board to evaluate incidents in which citizens were injured, killed or shot by police officers. By 1997, it had been dismantled. Last month, Flynn announced the formation of a new board to do the same thing.
• Since at least 1994, police have been trained repeatedly not to press their knees into the backs of suspects who are facedown and handcuffed, yet that's what an officer did to Williams, according to incident reports.

Reforms are not effective unless people take them seriously, said Laura R. Woliver of the University of South Carolina, who researched the Lacy case for her 1993 book, "From Outrage to Action: The Politics of Grass-Roots Dissent."

"It happens again because some of the reforms were just superficial, because the underlying structure that set up these confrontations hasn't changed," she said. "The training might not take if the people who are being trained don't have the passion to change their behavior."

Flynn has denied repeated interview requests. Approached by a reporter before a Fire and Police Commission meeting earlier this month, he said his goal is for those in the department to continue learning. He said he couldn't speak to whether his recently announced policies and procedures would be more effective than their counterparts in the past.

"We have to deal with the challenges that we confront, and this is an opportunity for us to put together something that can help us learn from critical events that could've been handled perhaps differently if we had had the appropriate training and protocols in place," Flynn said.

Injured in arrest

Lacy was arrested July 9, 1981.

He was picked up by police at 11:07 p.m. on the 2200 block of W. Wisconsin Ave. after a woman reported being raped by a black man. Officers were walking Lacy to a squad car when he tried to run away, police told the medical examiner. Lacy - who did not commit the rape - and the officers fell to the ground in the ensuing struggle, according to the police version of events.

The medical examiner documented more than 30 cuts and bruises on Lacy's body, according to the report, which the Journal Sentinel reviewed this month. Police, however, "claimed that they struck no blows during the struggle," the report says.

Witnesses said police held Lacy facedown in a gutter, with a knee on his back.

Officers placed a handcuffed Lacy on the floor in the back of a police wagon, according to the report. He was conscious, police told the medical examiner, "but apparently not alert enough to sit on one of the seats in the van." By 11:26 p.m., another prisoner noticed that Lacy was unconscious. Paramedics were called at 11:28 p.m. and arrived within three minutes. Lacy was pronounced dead about an hour later.

After three autopsies, the medical examiner ruled the manner of Lacy's death "undetermined."

Within days, community groups formed the Coalition for Justice for Ernest Lacy, staging demonstrations, lobbying for legislation and demanding the officers be held accountable and Chief Harold Breier be removed. The Common Council requested an investigation by the U.S. Department of Justice.

Breier quickly announced the officers had done nothing wrong.

The Milwaukee County district attorney's office and the Police Department's internal affairs division reopened their investigations after numerous public demonstrations.

One of the officers involved in Lacy's arrest eventually was fired for excessive force; four others were suspended. Then-District Attorney E. Michael McCann convened an inquest, which lasted 21 days and included more than 100 witnesses. Jurors recommended charges of reckless homicide and misconduct in public office. McCann issued the misconduct charges, but a judge later threw them out because there was no law on the books making it a crime for officers to fail to render first aid.

Breier refused to cooperate with the federal investigation, and the Justice Department did not pursue a federal civil rights lawsuit against police.

Thirty years later, on July 6, 2011, Williams was arrested.

Williams was taken into custody on suspicion of robbery after he ran from police. He had gotten out of jail earlier in the day on municipal warrants but had no criminal record.

He died after gasping for breath and begging for help for about eight minutes in the back of a police car as officers ignored his pleas, a squad video shows.

The video was posted on JSOnline in September after 10 months of public records requests and negotiations with the city. Officials at the Police Department, district attorney's office and city Fire and Police Commission all viewed the video months earlier and concluded the officers involved did nothing wrong. All three reopened their inquiries as a result of a Journal Sentinel investigation.

At autopsy, Assistant Medical Examiner Christopher Poulos documented 30 cuts, scratches and bruises on Williams' hands, arms, elbow, legs, feet, abdomen and back, according to the autopsy report. Williams also had a cracked hyoid bone in his neck, an injury that requires extreme force and occurs in just 30% of people who are fatally strangled. Poulos attributed Williams' cuts and bruises to jumping a fence and the cracked hyoid to resuscitation efforts.

Police told the medical examiner's office Williams was arrested "without incident." Poulos relied on that account and did not review police reports or the video before making his original ruling.

He changed the manner of death from natural to homicide after the newspaper provided him with police reports that showed force was used.

No use-of-force report was filed, although the department requires officers to complete them whenever the use of force results in injury.

The medical examiner's homicide ruling does not necessarily mean a crime was committed.

The FBI this month launched a criminal civil rights investigation into Williams' death. A public inquest led by a special prosecutor also will be convened to determine if state-level criminal charges are warranted.

In a separate inquiry, federal authorities in Washington, D.C., are researching whether to sue the Police Department for a pattern of civil rights violations - an investigation requested by numerous state and local officials.

Reform revisited

The Lacy case prompted numerous reforms, many of which were proposed again - as if they were new - after the death of Williams.

Flynn's promises to make changes have come amid calls for his removal by ministers and community activists, who have cited Williams' death and other problems in the department, including charges related to illegal cavity searches for drugs, the detention of the mother of a slain boy and inaccurate reporting of crime statistics.

Duty to help: Flynn's first pledge was a requirement that police get medical help for prisoners. Officers should err on the side of caution and call for an ambulance if they have any sign someone is in medical distress, he said.

Last month, Flynn issued an internal memo explaining what medical distress is and directing officers to call paramedics if a prisoner experiences symptoms such as trouble breathing or pain. Officers also are receiving training on how to recognize the signs of respiratory distress.

A law that criminalized failing to get medical help for prisoners was passed in 1983, after lobbying by the Lacy coalition. Getting medical attention for prisoners also was mandated by Police Department policy, which still says: "Members shall remain cognizant of any changes in the condition of an arrestee that would require medical treatment. If medical treatment becomes necessary, members shall immediately request medical assistance by telephone or radio.

"It cannot be overemphasized that members shall continually monitor and remain cognizant of the condition of a person in custody, especially when he/she is in restraints. The arrestee may encounter immediate or delayed physical reactions that may be triggered by the change in physical or environmental factors."

The difference, according to Flynn, is that officers are now required to call for help whether they believe a prisoner's complaints or not.

Police training, however, already taught that, according to police sources. Officers have previously been instructed that even if they believe a prisoner is faking because he does not want to go to jail - a common circumstance nicknamed "jailitis" - they should call for help anyway to protect themselves from liability.

Flynn said he didn't know anything about officers receiving such instructions.

"All I know is what I've got in writing. I don't know what they've previously been told," he said. "We've changed the protocol. We've removed that discretion from them and if somebody complains of shortness of breath, we're going to call an ambulance. A lot of ambulances are going to get called to a lot of police cars, and they will not be needed, but we've decided we can't take that risk anymore."

Attorney Jonathan Safran, who represents Williams' girlfriend and their three young children, said it was hard to believe officers didn't already know when they should call for help.

"I was surprised that the chief would have to either reissue or issue a memorandum that would seem to confirm the obvious," he said.

Review board: Another change Flynn touted as a result of the Williams case was the formation of a review board to evaluate serious uses of force and in-custody deaths

That also was not a new idea.

During the Lacy era, Mayor Henry Maier appointed a group of community members, known as the Lacy Monitoring Committee, to keep an eye on the various investigations into Lacy's death. That committee was a precursor to a formal, "permanent" review board.

That board was formed in 1992, about 10 years later, after the police shooting of Tandy O'Neal and the death of Nicholas Elm.

O'Neal was rendered a quadriplegic at age 29 after police shot him in the back during a drug raid at his home. A police detective initially said O'Neal had struggled with officers but later admitted that was not true, according to court records.

Elm, 32, fought with police and people on the street after he tried to throw a brick through a window and pulled a girl out of a car by the hair. He died facedown and handcuffed in the back of a police wagon. The medical examiner documented injuries to his head, shoulder and elbow, which were ruled the result of "blunt trauma at the hands of another," according to media reports at the time.

The review board's job was to evaluate police responses to incidents such as those involving O'Neal and Elm, in which citizens were injured, killed or shot during interactions with police officers. After reviewing the incidents, the board would recommend policies to improve training.

The board reviewed nine cases from 1992 to 1994, according to court records. It had disbanded by 1997.

Last month, Flynn announced the formation of a similar board.

The board consists of Flynn's top commanders, and they will report findings to Flynn and to Michael Tobin, executive director of the Fire and Police Commission. According to a new standard operating procedure that describes the board, Flynn has the final say on whether changes should be made as a result of each review. Tobin, an attorney and former Milwaukee police officer, has said the commission will settle the issue if a dispute arises between him and the chief. But that is not set out in writing.

Attorney Mark Thomsen, who has represented victims of police brutality for 20 years, said a board full of police insiders is unlikely to result in meaningful improvements.

"Ultimately, the City of Milwaukee will have to adopt an ordinance that establishes an independent critical incident review board, and until we do that as a community, we're never going to see this thing change," he said.

Restraint procedures: Both Lacy and Williams died after police held them facedown with a knee to the back.

Since 1994, Milwaukee officers have been trained not to restrain people that way.

If they do, they are at risk of causing positional asphyxia, which is the inability to breathe due to the position of the body. It can be caused by physical restraint, especially if someone is held facedown and handcuffed, according to experts.

Beginning in 1994, Milwaukee police officers watched a training video that instructed them to get prisoners off their stomachs as soon as they were handcuffed, refrain from sitting on their backs, and get them immediate medical attention, if required, according to court records.

"As soon as the person is handcuffed, get him off his stomach," the video says. "Turn him on his side or place him in a seated position."

In April 1997, the department issued a written training bulletin reiterating the points in the video.

Less than three weeks after the 1997 bulletin was issued, police were called to the apartment building of Thomas Jackson, 33, amid reports he was refusing to let a woman off an elevator. Police held Jackson facedown with a knee on his back while he was handcuffed, court records say.

He was transported to the hospital facedown, handcuffed, shackled and strapped to a gurney. Jackson, who was mentally ill and believed to be off his medication, died of positional chest compression and possible neck compression, according to the medical examiner's report.

In a civil suit filed on behalf of Jackson's estate, then-Chief Arthur Jones testified that officers had been trained on the dangers of positional asphyxia.

"(If), objectively the officers or officer could have placed the person on their side or in a sitting position, failure to do so would have been a violation of standard operating procedures," Jones said.

Training on positional asphyxia still is in use today, Flynn said.

In the Williams case, police reports show officer Richard Ticcioni "ended up on top of Williams with the suspect facing down," as officers tried to take him into custody. They then handcuffed him.

Williams first said he couldn't breathe as he lay facedown with Ticcioni's right knee against his left shoulder, according to the report of Detective Luke O'Day, who interviewed Ticcioni.

"As soon as he released pressure, Williams began squirming, as if trying to break free, and reached around his right side to his right waistband (while still in handcuffs)," according to the report. Ticcioni worried that Williams was trying to grab a gun and "reapplied pressure with his right knee to prevent any further movement from the suspect," the report says.

Officers then searched Williams. No gun was found.

The main reason to put pressure on someone's back is to stabilize him so handcuffs can be applied, Flynn said. He would not answer a question about when it might be appropriate to continue applying pressure after the cuffs are on.

"The point is, they used their professional judgment in a dynamic situation," he said of the officers involved in Williams' arrest.

Flynn continues to say Williams' death was a natural sickle cell crisis brought by "physical exertion" or "physical pursuit."

The amended autopsy is more specific. Although it maintains sickle cell crisis as the cause of Williams' death, it says the death was a homicide - or "death at the hands of another" - which occurred due to "flight from and altercation with police."

Sickle cell crisis has been the subject of debate in the medical community when it occurs in people such as Williams, who had the genetic marker, known as sickle cell trait, but not the disease itself. The crisis occurs when someone is deprived of oxygen. Doctors at the National Institutes of Health say people with only the trait cannot die of sickle cell crisis. Some pathologists counter that it can happen in rare cases.

Flynn defended the actions of Officers Jeffrey Cline and Jason Bleichwehl, who each took a turn sitting in the front of the squad car while Williams struggled to breathe in the back.

"The point of seeing the tape is that the cops at no time act disrespectful," Flynn said. "They don't believe him. . . . (They are) not being nasty to him. The point is: That's different than treating somebody badly."

Flynn has defended the officers by saying they could not have recognized Williams' condition because sickle cell crisis is so unusual.

But others counter the reason Williams was having trouble breathing is irrelevant - it was clear he needed help.

"There are hundreds of people like that who don't have sickle cell crisis who die of exactly the same thing: In prone restraint, with pressure on their back, with immobilization of the chest," said Werner U. Spitz, a forensic pathologist and one of the nation's leading experts on death investigation.

Attorney Robin Shellow, who represents Williams' mother, said his death shows police training has not been effective.

"It is my guess that the Ernest Lacy story was omitted from the current curriculum at the Police Academy," she said.

Ald. Milele Coggs, who has been at the forefront of calls for reform since Williams' death, said history will continue to repeat itself unless officials and community members come together to implement real changes.

"Today it is the Williams family suffering. Thirty years ago it was the Lacy family suffering," she said at a community meeting last month. "Today it was Derek and tomorrow it can be somebody else if we do not, in a collective way, go about dismantling this system of injustices."