TUCSON, Ariz. — Leaders of the Tucson Police Department had heard a little about the video. Now, for the first time, they would judge for themselves how grim it was.
As the top brass gathered in a conference room at headquarters, Tucson was, like much of America, protesting the killing of George Floyd. It was June 2020. This body-camera footage could be the tipping point.
The video started. It was nighttime. Three officers strode up to a modest home. A 66-year-old grandmother had called 911 after her 27-year-old grandson became aggressive.
Carlos Adrian Ingram Lopez was naked and high on cocaine when the officers confronted him in the house’s cramped, unlit garage. One officer told him to get on the ground and he did, a flashlight briefly showing him on all fours.
In the darkness on screen, the sound popped out. Ingram Lopez wailed, pleaded, apologized as officers cuffed his hands behind his back.
There was a heaviness in the conference room. The body language around the table was bad, the reluctance to talk telling.
The footage was not done, but the chief and his team didn’t need to see any more, not right then. They all knew how this ended.
The meeting broke and the reckoning began.
Well before Floyd’s murder in May 2020, Tucson was among America’s big-city departments to embrace “progressive policing.” Members of the same leadership in that conference room had launched programs to get nonviolent drug dealers and homeless people services, rather than incarcerate them, and new training to teach officers to de-escalate difficult and dangerous situations.
Then-Chief Chris Magnus was a leader within progressive policing who had, as chief in Richmond, California, appeared in uniform at a protest holding a Black Lives Matter sign. Two weeks before watching the Ingram Lopez video for the first time, he reflected on Floyd’s death in a newspaper column.
Progressive police departments, Magnus wrote in the Arizona Daily Star, work hard to prevent such deaths through training, supervision, accountability and transparency. Tucson, he wrote, was “ahead of the curve” in these areas.
Now, Magnus’ department had a death that involved not just rapid escalation to force but also – like Floyd – a person telling officers “I can’t breathe” as they held him face down.
An Associated Press reconstruction of what followed, based on text messages and internal investigative files, shows how a department’s attempts to limit force don’t always filter down to the street, and how internal culture can shape what a department tells the public.
“We were sitting here going — when George Floyd broke — thinking, man, that can never happen here,” Chad Kasmar, the No. 2 under Magnus who took over when the chief left in 2021 to lead U.S. Customs and Border Protection, told AP of this Democratic-leaning city of 542,000 people. “And what we hadn’t recognized is we had a very similar incident that people were going to connect.”
In the early morning of April 21, 2020, police came to the house of Ingram Lopez’s grandmother after she reported that her grandson was naked, under the influence of drugs and acting erratically.
Ingram Lopez had struggled with substance abuse, was unemployed and hadn’t gotten much sleep in his last days. Inside the home, he was hallucinating. His grandmother tried to leave, but he blocked and pushed her. Frightened, she called 911.
A dispatcher told responding officers Ingram Lopez had a domestic violence arrest warrant. Two days earlier, the mother of his young daughter reported that he pushed her in the chest during a dispute over her laptop. Ingram Lopez was staying with his grandmother because the woman had kicked him out.
None of the first officers to arrive discussed a plan — a basic best practice that would later be emphasized in the department’s training. Aside from telling Ingram Lopez to relax, they did little to calm the encounter, even when he soon started cooperating.
Officers cuffed Ingram Lopez’s hands behind his back and kept him for 12 minutes on his stomach, a position known as prone restraint that can dangerously restrict breathing. During the handcuffing, two of them put knees on his back, while a third held his legs, according to internal interviews of the officers. The officers would later be found to have violated several departmental policies, including for their use of force.
One who believed Ingram Lopez remained a danger didn’t turn him from his stomach onto his side so his airway could remain clear. Officers ignored Ingram Lopez’s complaint that he couldn’t breathe and his 21 pleas for water.
Due to concerns about an emerging virus called COVID-19, officers placed a spit sock over Ingram Lopez’s face. Blankets draped over his head and naked torso made it harder to monitor breathing. One of the officers had previously worked as an EMT but had not requested paramedics.
Ingram Lopez was dying, yet nearly two minutes passed from when he made his last sound to when officers turned him off his stomach at the request of an arriving supervisor.
The supervisor pulled up the spit mask, and he and another officer started CPR. Within about half an hour, Ingram Lopez was pronounced dead. In an autopsy, a medical examiner concluded Ingram Lopez died from “sudden cardiac arrest in the setting of acute cocaine intoxication and physical restraint” and that his enlarged heart was a contributing condition.
He was one of more than 1,000 people who died over a decade after police subdued them using force that is not supposed to be lethal, an investigation led by The Associated Press found. In hundreds of those encounters, officers violated long-established safety practices. The investigation was done in collaboration with The Howard Center for Investigative Journalism programs at Arizona State University and the University of Maryland, and FRONTLINE (PBS).
In Tucson, Ingram Lopez’s grandmother blamed herself, family would tell an officer investigating the death. “She should have just taken a beating” is how family members summarized her anguish.
Jolting as it was, the video raised a deeper question: Why did it take nearly eight weeks for the department’s leaders to see it?
The department immediately opened an internal affairs investigation into Ingram Lopez’s death — a standard practice to determine whether officers broke any rules.
A series of texts the AP obtained under a public records act request shows how the internal affairs commander responsible for that investigation downplayed the full range of failures. The text conversation was between Lt. Jennifer Pegnato, the commander who was investigating the death, and her boss, Assistant Chief Michael Silva.
In the overnight hours after the encounter, Pegnato reported to Silva that investigators found white powder at the grandmother’s house, that Ingram Lopez had been acting bizarrely, and that a few minutes had passed between when he was detained and when a supervising sergeant arrived.
She also referred to the officers’ body-worn camera video. Based on her initial assessment, the officers could have rolled him from his stomach to his side sooner.
“But,” she wrote, “no force was used.”
The next day, Silva texted to check on interviews of the officers, who had worked for the department between 18 months and five years.
“Nothing earth shattering thus far,” Pegnato replied.
She texted again a bit later. “I think this is a case of several young inexperienced officers,” she continued. “They will likely need some additional training. Some poor tactics were utilized and no one really had a plan.”
Silva then asked Pegnato if she wanted to bring any investigators from her staff to an initial briefing for the brass.
The two sergeants helping Pegnato with the investigation were split. Like her, one of them believed no force had been used — but the video shocked the other sergeant, who considered it among the worst he had seen, records show.
“I’ll cover it,” Pegnato wrote Silva of the meeting. “I think I’m well versed. And hoping with just me I can help keep it brief. :)”
The pandemic was unfolding and people were scattered, so Pegnato scheduled a remote meeting on the Microsoft collaboration platform Teams for two days after Ingram Lopez’s death.
During the meeting, Pegnato didn’t show the video. She later said Teams was new to her and that posed challenges. She would recount that she thought she described some of what she saw on the video, and said a lot could have gone better.
Seven weeks later, on June 15, the leadership finally saw for itself.
The internal affairs investigator who was shocked by the video but wasn’t invited to the first meeting made sure to go this time, even though it was his typical day off. Several attendees recalled how the bosses’ faces showed that they hadn’t previously understood the gravity of the encounter.
They described Chief Magnus as displeased, disappointed and appalled. Magnus did not grant an interview request.
Department leaders understood immediately that people would see parallels between Ingram Lopez and Floyd. And that the public would suspect a cover-up, since the public hadn’t yet been told and the officers were back on duty within three days.
“It was a heavy meeting where everything’s flooding against you,” then-Deputy Chief Kasmar recalled.
The department wasn’t ready to go public.
Magnus would later say they waited to reveal the death until after Ingram Lopez’s family could watch the video. But eight days after leadership saw the video, local news media broke the story of the death.
The next day, June 24, Magnus addressed the public.
Stepping to news conference microphones, flanked by the mayor and a sign language interpreter, Magnus removed the mask covering his face. He began by saying he and others at the department were troubled and were committed to accountability and transparency.
Magnus then summarized the encounter. Ingram Lopez faced domestic violence allegations, had been restrained face down for about 12 minutes and went into cardiac arrest. He was on cocaine and had a preexisting heart condition. Although Ingram Lopez started out acting erratically, he soon became compliant.
Magnus said the three officers didn’t have malicious intent but had violated department policy and would have been fired had they not already quit.
The video began on a large screen and ended 22 minutes later, with officers and firefighters trying to revive Ingram Lopez.
“This is now the 18th time I’ve watched it,” Magnus said, “and it frankly never gets any easier.”
Magnus then acknowledged he and other top managers should have watched the video sooner. The public should have been notified earlier, too, but he didn’t think there had been a calculated cover-up.
“I realize that, given the times we are in, any mistakes of this kind are viewed with great suspicion,” Magnus said.
Even as he promised transparency during the news conference, Magnus didn’t disclose something else: Just a month before Ingram Lopez’s death, another Hispanic man died after Tucson officers restrained him.
Damien Alvarado ran from a car crash in March 2020. A man and his son who had witnessed the immediate aftermath of the wreck spotted the 29-year-old in a bush behind a church. The man and an officer who had just arrived had grabbed Alvarado’s legs as he tried to climb over a cinderblock wall.
The officer brought him to the ground and punched Alvarado, whose hands, the officer said, were moving toward his gun. More officers arrived. Alvarado resisted handcuffs and threatened them. Police shocked him several times with a Taser and used two devices to restrain his legs.
During the four minutes they held him down, an officer put a knee on Alvarado’s back. Both officers and paramedics put a spit mask over his face. When Alvarado complained he couldn’t breathe, one officer profanely told Alvarado to shut his mouth.
Paramedics were preparing to leave but were called back when his breathing became labored, then stopped. Officers began CPR and paramedics brought him to a hospital, where he was pronounced dead.
Alvarado’s mother Irene remembers Damien as a skilled carpenter with a zest for life. Like Ingram Lopez, Alvarado left behind a young child. “He didn’t deserve to die,” Irene Alvarado said in an interview as she wept.
The Pima County Medical Examiner’s Office concluded the death was an accident caused by “cardiac arrest in the setting of acute methamphetamine intoxication and restraint.” All officers were cleared for their use of force, but two were disciplined for foul language.
Two weeks after Magnus’ news conference and more than three months after Alvarado’s death, the department revealed the encounter to the public — through a news release.
At the news conference, Magnus had offered to resign. The city manager declined the next day, citing his community policing efforts and talent for changing the department’s culture.
Those efforts would be tested, as the Ingram Lopez death galvanized protesters.
Still deputy chief, Kasmar reviewed the department’s internal investigation and leveled a withering critique. Pegnato should have realized the officers’ failures far exceeded “re-training opportunities,” Kasmar wrote, and she failed to grasp the city’s legal liability when the officers kept holding Ingram Lopez down despite his medical distress.
Kasmar also criticized the department’s executive leadership team, which he said should have asked to see the video. AP sought to speak with Silva but he did not respond to interview requests. Pegnato, whose last name is now Pegnato Moss, declined to be interviewed.
Police leaders undertook a new kind of accountability called a sentinel event review board, a public investigation typically used in the hospital and airline industries to learn from mistakes. Departments tend to avoid them because the findings can become fodder in wrongful death lawsuits.
In the end, the review board offered dozens of recommendations. Months after the inquiry, the department detailed changes it made.
In response to the lack of planning and rapid escalation with Ingram Lopez, the department gave sworn officers new training in November 2020. There were also trainings on recognizing medical distress, calling EMS and monitoring breathing – courses that are continuing today, according to Kasmar.
Parallel reforms required quicker action. Two chiefs and the chief of police now review body-worn camera footage within two days of a death, and footage must be made public within three days. All restraint deaths get the same level of review as officer-involved shootings.
Other changes included dispatching the fire department with police on narcotics calls to administer aid quickly. The department discontinued use of spit socks, and each new internal affairs staffer would get a training program and a mentor sergeant.
Michael Scott, a criminal justice professor at Arizona State University and former police chief in Florida, helped conduct the Tucson review board’s investigation. He’s long pushed departments to adopt these kinds of boards to build transparency and trust.
“Doing nothing, changing nothing is not really an option,” Scott said in an interview.
The department takes learning from critical incidents like Ingram Lopez’s death seriously, Kasmar said. The question becomes how well officers embrace those lessons.
“Culture,” he said, “eats policy for breakfast.”
Tucson has picked most of its chiefs from within and Kasmar is a third-generation Tucsonan “raising a fourth.” Kasmar attended his hometown’s University of Arizona, earning a fine arts degree. The year after he joined in 2000, people rioted after the school lost the men’s college basketball title game. Officers fired beanbags and wooden dowels at them, striking 40 people, including a student who lost an eye.
Kasmar worked his way up, including stints as a patrol officer and commander of internal affairs. Now in charge, Kasmar believes change can come, even if slowly. Getting the department’s 1,200 people to follow along takes time, he said – and persistence.
“Across this country we have these, you know, expectations for these immediate shifts in culture,” Kasmar said. “But what we don’t have any grace for is the fact that human beings in general are difficult or resistant to change.”
Under Kasmar, the department has paid an anthropologist to examine its training and culture. Some review board members were concerned systemic racism might have influenced officers’ responses with both Latino men.
Victor Braitberg, a University of Arizona cultural anthropologist, began working as a private consultant for the department in January 2021, conducting a yearlong examination. He has since done other paid work for the department.
Braitberg said officers earnestly believed that racism and bias were not a problem in their ranks. He also found a division between officers and leadership on the role bias was perceived to play in the two deaths. The rank and file didn’t feel the brass had their back.
That view began to change, Braitberg said, with Kasmar, whose approach included running with recruits and checking in with detectives. Braitberg said he thinks the department’s culture is improving and that officers and leadership are more aligned.
Kasmar said his department’s not perfect and has been working to rebuild trust.
“I think we’re doing everything in our power to be a transparent police department and set a tone for other organizations in the country to follow,” he said.
One indicator of cultural change in the department, he said, was that for the first time in five years, the agency began the year with a handful more officers than it had in the previous year – a reversal of a trend after the deaths of Floyd and Ingram Lopez. He pointed to a program that helps officers deal with trauma and recognize “it’s OK to be human – it’s OK to show emotion,” Kasmar said.
Hard skeptics question whether Tucson police can change. Paul Gattone, an attorney representing Alvarado’s family, said officers see civilians as a potential threat rather than people who need their protection. “They are a product of what we’ve allowed the police to become,” Gattone said.
Tucson is fighting the Alvarado lawsuit, arguing that officers acted reasonably. On the other hand, the city paid $2.9 million to settle legal claims over Ingram Lopez’s death.
It’s not only the police department’s culture that would have to change to improve police-community relations, according to Caroline Isaacs, a longtime Tucson activist with Just Communities Arizona.
Internal reforms can be hard because criminal justice often presents itself as adversarial, and there’s not great communication between those in the system.
“It’s always us against them,” she said. “There’s so little dialogue on both sides, and that creates no room for — you know – accountability.”
Contributing were Jessica Alvarado and Taylor Bayly in Tucson and Courtney Cohn, Kate Seltzer, Sarah Elizabeth Siock and Minnie Stephenson in College Park, Maryland.
Editor’s note: This story is based on two 70-page police reports and 2,000 pages of internal affairs records on Ingram Lopez’s death; 280 pages of police reports and a separate 950-page internal affairs report on Alvarado’s death; records in both deaths including body-camera video, an 80-page sentinel event review board report, autopsy and toxicology reports, lawsuits and legal claims, officer personnel records, and letters from prosecutors; and interviews with Police Chief Chad Kasmar, former City Manager Michael Ortega, Alvarado’s mother, attorneys representing both families, a cultural anthropologist hired by the department, a community activist and five policing experts.
