Officers from the three Lafayette Parish law enforcement agencies who encountered Robert Minjarez Jr. in his final waking moments had dealt with him before.

The 30-year-old from Scott struggled with cocaine addiction for at least a decade, with manic episodes involving severe paranoia and hallucination. Law enforcement were often called to manage the situation, with Minjarez more often sent to a hospital than jail for his erratic and uncontrollable behavior.

But before medics arrived at a north Lafayette gas station on the evening of March 2, 2014, to assist the seven law enforcement officers who responded to another of Minjarez’s episodes, he lost consciousness while restrained and held face-down on the pavement, according to documents and video in a State Police investigative file. His paranoid screams — “Why are you trying to kill me?” — morphed into labored groans and cries of “I can’t breathe” that went unanswered during the five minutes he lay prone, his lower body elevated on a curb and his upper body below it.

More than four months before the high-profile death of Eric Garner during an arrest on Staten Island, New York City, made the phrase “I can’t breathe” among the rallying cries uniting a movement protesting police brutality, Minjarez never regained consciousness and died five days after his encounter with police.

A Lafayette Parish forensic examiner ruled his death a homicide, but criminal investigators at the state and federal level, along with a Lafayette Parish grand jury, declined charges against the officers involved.

Three use-of-force experts interviewed by The Acadiana Advocate said sudden deaths during arrests are complicated issues for both law enforcement officers and the people they serve.

But after reviewing records from the Minjarez encounter, those experts also raised questions about how law enforcement officers that night physically restrained and pinned down a nonviolent, unarmed man suffering an obvious and severe mental crisis — the kind that puts its sufferers at a high risk for sudden death.

‘You’re going to kill me!’

In his final minutes of consciousness, Minjarez had been pacing in front of the Texaco on Pont Des Mouton Road — seemingly hallucinating — while his two young children and their mother were inside. The store clerk reported his behavior to police, but Minjarez had already called 911 himself — nine times.

At 6:52 p.m., Minjarez made the first call to 911, screaming that someone was trying to hurt and shoot him. In the middle of his eighth call, a Lafayette Parish Sheriff’s Office deputy and her canine arrived at 7 p.m., according to documents and video included in Louisiana State Police’s criminal investigation into the incident.

Minjarez immediately put his hands in the air but refused the deputy’s commands to turn around and put his hands behind his back. Another Lafayette deputy arrives a minute later and tries unsuccessfully to restrain him.

The pair of deputies, one also handling her canine and the other with a stun gun, then stand facing the unarmed Minjarez, who continues his paranoid shouting but leans against the front of the store with his hands in the air. Three more officers, from the Scott and Carencro police departments, arrive almost simultaneously, and the group repeatedly commands Minjarez to get on the ground.

“He did not even seem to comprehend that he was being ordered to do anything,” Hayden Godeaux, one of the Scott Police officers on scene that night, said in an interview included in the State Police investigation.

“We kind of, as all officers often do, non-verbally agree to rush him,” Godeaux said.

By 7:04 p.m., Minjarez was restrained and on the ground, but he continued to struggle and yell.

“I didn’t do anything! I didn’t do anything!” he yelled. “Help! Help! Help me! Get off! You’re going to kill me! You’re going to kill me! You’re going to kill me!”

At 7:06 p.m., an ambulance is dispatched to the scene. And in the same minute, as at least two officers continue to hold him down, Minjarez is heard in dash-cam footage at 7:06 p.m. saying, “I can’t breathe.”

Minjarez repeats “I can’t breathe” at least four more times amid the same type of paranoid yelling recorded in his 911 calls several minutes earlier. He yells out for help and continues shouting, although the groans become more laborious as the seconds pass.

While the officers talk among themselves — some of them had dealt with him before, including in an incident the night before — Minjarez continues to call for help, breathing hard and gasping for air. He was still resisting and kicking his legs, prompting the officers to shackle his legs, according to officers’ accounts of the incident. One is heard in dash-cam footage advising Minjarez to relax.

As he continues screaming, his voice grows more hoarse.

At 7:10 p.m., he groans once more and is never heard from again.

“You got 265 pounds on your back, dude. You’re not going anywhere,” Carencro Police officer Joshua Alvarez tells him.

Within a minute, the officers realize Minjarez had stopped responding, and only then is he rolled onto his side. Three minutes later the ambulance arrives.

Medics, who noted in their reports Minjarez had no pulse and had blue ears when they arrived, were told by the officers Minjarez was suffering from “excited delirium,” and they cautioned the medics to have restraints ready for “when he wakes up.”

He never did.

Following procedures

Excited delirium involves psychotic behavior, elevated temperatures and is most often linked to cocaine use. The condition puts its sufferers at a “high risk for sudden death,” said Deborah Mash, a neuroscientist and researcher with the University of Miami Miller School of Medicine.

It’s unclear what training local law enforcement offers to its employees on the risks of encountering individuals suffering excited delirium, or any mental health episode at all.

The three agencies involved in the Minjarez incident — the Lafayette Parish Sheriff’s Office and Carencro and Scott police departments — have been tight-lipped on the topic since March, when the mother of Minjarez’s two children filed a federal wrongful-death lawsuit. They declined to address the critiques raised by experts for this article.

Each agency, however, maintains that even though Minjarez died, its officers’ actions that night adhered to policy.

Of those three law enforcement agencies, each has a use-of-force policy listing a “use-of-force continuum” that begins with an officer’s presence on the scene and escalates to verbal commands and then the use of “soft empty hand” controls, in which an officer uses grabs and holds to restrain a noncompliant individual.

Carencro Police Chief Carlos Stout said his department found no policy violation in his officers’ actions that night. Scott Police Chief Chad Leger said no internal review was conducted because “this case was turned over for investigation to Louisiana State Police and the FBI.”

Leger declined further comment on the matter because of the pending litigation.

The Lafayette Parish Sheriff’s Office filled out a single-page use-of-force review form for one of its deputies said to have used the soft empty hand control technique to subdue Minjarez that night.

“Had the use of force been determined ‘unjustified or in violation of policy,’ a formal investigation would have been opened. But that simply did not occur,” Lafayette Parish Sheriff’s Office spokesman Capt. John Babin said.

“We feel this matter has been thoroughly reviewed” by the Lafayette Parish Sheriff’s Office, Louisiana State Police, the FBI and a Lafayette Parish grand jury, he added.

Although criminal investigators may believe there is no wrongdoing in cases such as Minjarez’s, additional internal investigations into an officer’s actions are necessary when a death occurs, said Samuel Walker, an emeritus criminology professor at the University of Nebraska at Omaha who now works as a consultant on policing and criminal justice policy.

Law enforcement should not just do a use-of-force review, but take a broader look at an incident to analyze if officers could have done anything to change the outcome, he said.

“That is the new and emerging standard in policing. You have parallel investigations. One is determined whether the officer did something wrong or not — complied with policy or violated policy,” Walker said. “The second entirely separate one — and you really need a wall of separation between the two — is to use it as a learning opportunity.”

Experts see errors

Mash, the neuroscientist who researches cocaine’s effects on the brain and is often called to testify on in-custody deaths, reviewed Minjarez’s autopsy report, which lists the cause of death as asphyxia “due to face-down physical restraint by law enforcement officers,” with muscle breakdown and cocaine toxicity cited as contributing factors.

It does not mention excited delirium, a diagnosis controversial in the medical field that law enforcement officers mentioned when medics arrived outside the gas station.

Two of the officers knew something of Minjarez’s recent history. Godeaux, one of the Scott Police officers, and former Lafayette Parish Sheriff’s Office Deputy Jill Birkenmeier — both were on scene the night Minjarez lost consciousness — responded to a call the night before in Scott, where a nude and agitated Minjarez had torn apart his trailer, according to their accounts of the incident.

In that instance, along with two others in the eight months before his death, Minjarez was restrained, sedated and admitted to a hospital rather than being placed under arrest. Medical information included in Minjarez’s autopsy notes he had a temperature at 103 degrees Fahrenheit upon his admission to the hospital on March 1, 2014, and he also was diagnosed with rhabdomyolysis, or muscle breakdown, before leaving the hospital against medical advice.

Excited delirium causes a person’s body chemistry to become acidic, thus reducing the amount of oxygen in the blood and, in Minjarez’s case, contributing to the day-earlier diagnosis of muscle breakdown and cocaine toxicity he already was experiencing, Mash said.

Yet even without knowledge of Minjarez’s medical conditions, Mash said the officers that night erred in waiting until he was restrained to call an ambulance.

“Excited delirium is a medical emergency. These (law enforcement officers) failed to recognize that,” Mash said. “They did not call an ambulance until after he was in cardiorespiratory distress. They should have immediately.”

It’s a criticism echoed by use-of-force expert and retired Los Angeles Police Department Capt. Greg Meyer, who reviewed both dash-cam footage from the incident and Minjarez’s autopsy report and agreed the officers needed to restrain Minjarez — just not so quickly.

“When you come across someone that’s in this condition, what we call it is a medical problem disguised as a police problem,” Meyer said. “If there’s not violence occurring, if no one is in immediate danger, wait it out, call the medics, wait until they get there if you can, and then restrain him and turn him over to the medics so that he can be sedated or do whatever they have to do to keep him calm.”

Once he’s handcuffed, “ideally, their training is that you take the weight off of him and you turn him over on his side, which facilitates the breathing a little better,” Meyer said.

Officers did not get Minjarez on his side until they realized he lost consciousness, more than a minute after his final utterance and five minutes after he had been restrained face-down on the pavement with at least two officers leaning into his body while the lower half of Minjarez was elevated upon a 5-inch curb.

“One of the problems that is emerging as a pattern is that officers are too quick to use restraints with people who are out of control — having a mental health issue, for example — and to essentially force the issue as opposed to giving the person space and time,” said Walker, the criminologist. “If he’s not hurting anybody, if he doesn’t have a weapon, where is the danger?”

Follow Lanie Lee Cook on Twitter, @lanieleecook, or contact her by phone at (337) 534-0825.