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THE BISARD EVIDENCE
   BISARD’S BLOOD SAMPLE – VIAL TWO
                                   Prepared By:
                              Ellen M. Corcella. Esq.
                      Chief, Professional Standards Division
                          Department of Public Safety




Assigned investigators: Sgt. Dawn Higgins and Detective Michele Rusk of the
       Professional Standards Division, Department of Public Safety.
I.          INTRODUCTION.

       On August 6, 2010 Officer David Bisard, a sworn police officer for the
Indianapolis Metropolitan Police Department (IMPD), was involved in a fatal crash while
on duty. As part of the initial crash investigation, two vials of blood were drawn from
Officer Bisard. The vials of blood are referred to herein as Vial One and Vial Two.
Officer Bisard is currently facing criminal charges as a result of this crash in The State of
Indiana v. David Bisard, Cause No. 49G051101FB002516 (hereinafter the “Bisard
Case”).

        On April 16, 2012 at 8:00a.m., Marion County Prosecutor Terry Curry informed
then IMPD Chief of Police Paul Ciesielski that one of the two blood samples drawn from
David Bisard, commonly referred to as “Vial Two” was not stored in a refrigerated unit
for a period of time. The prosecutor gave Ciesielski a chain of custody report for Vial
One and Vial Two that demonstrated Vial Two had been in unrefrigerated storage. Chief
Ciesielski notified Director of Public Safety Frank Straub. Director Straub, in turn, asked
Ellen Corcella, Chief of Professional Standards, to determine the circumstances that
caused Vial Two to be held in non-refrigerated storage. As part of the investigation, all
civilian and sworn personnel involved were interviewed and all relevant documents
reviewed.

       a.   Summary of Factual Findings

       The investigation found that Vial Two was maintained and preserved in the
IMPD’s refrigerated storage from on or about August 6, 2010 until August 9, 2010. On
August 9, 2010, Vial Two was transferred to the Indiana State Department of Toxicology
(“ISDOT”), where it was maintained in refrigerated storage. On August 25, 2010, Vial
Two was retrieved from the ISDOT and returned to refrigerated storage in the IMPD
Property Room. On November 3, 2011, Vial Two was transferred to Property Room
Annex J where it was stored without refrigeration until April 5, 2012. Since April 5,
2012, Vial Two has been stored in refrigeration in the IMPD’s Property Room. At no time
between August 6, 2010 and the present was the vial cap securing the blood sample
within Vial Two ever removed. Vial Two’s seal remains intact.

       b. Summary of Conclusions

        A lack of clear policies and procedures, inadequate supervision, and a failure to
properly safeguard the Brisard evidence ultimately led to Vial Two being removed from
refrigeration in the Property Room and transferred to a non-refrigerated location in
Property Annex J. The IMPD Property Room does not have procedures or policies for
many of its primary duties and responsibilities. There are no storage or handling
protocols for blood evidence. To the extent that policies and procedures exist, they are
outdated, poorly constructed, and do not provide adequate guidance or protocols for the
demands placed on IMPD property room personnel. Direct responsibility for the
operation of the IMPD Property Room is placed in the hands of civilian personnel. The
IMPD command staff does not provide sufficient oversight of the Property Room.

                                       Page 2 of 16
Neither the Property Room’s civilian personnel nor its IMPD commander were properly
trained in evidence handling or in property room management. They have not been
trained in the proper storage protocols for blood evidence. As a result of these gaps in
existing systems, policies and supervision, Vial Two was improperly transferred to
unrefrigerated storage in Property Annex J.




                                     Page 3 of 16
II.    STATEMENT OF FACTS

        On August 6, 2010, Lt. Stan Stephens of the Lawrence Police Department, and a
member of the Fatal Accident Team (FAT), placed two vials of blood in the IMPD
Property Room under IMPD Case # DP100114281. These vials contained blood drawn
from IMPD Officer David Bisard, who had been involved in a fatal crash earlier in the
day. When Lt. Stephens turned the two blood vials into the IMPD Property Room, the
vials, along with other evidence collected in the Bisard matter, were assigned control
number “AC 10015325” and case number “DP10114281.” It is standard procedure to
draw two vials of blood. Vial Two was placed into a manila evidence envelope as is the
protocol for packaging blood vials for evidence. The standard evidence envelope used by
the property room is shown in the photograph below:




Standard evidence envelope used to store blood vials.


        On August 9, 2010, at about 3:14 p.m., IMPD Sgt. Douglas Heustis retrieved
numerous blood samples from the IMPD Property Room, including Bisard's blood
sample contained in Vial Two. Vial Two was in a standard evidence envelope. Sgt.
Heustis transported the blood vials to the ISDOT. Sgt. Heustis has been assigned the task
of transporting blood vials to the ISDOT since approximately 2007. According to all
parties with experience in handling blood evidence related to Operating Motor Vehicle
While Intoxicated (OVWI) cases, one blood vial is routinely tested by the Indianapolis-
Marion County Forensic Services Agency (FSA) for blood alcohol content (BAC). The
second blood vial is transported to the Indiana State Department of Toxicology (ISDOT)
where it is tested for the presence of drugs. Sgt. Heustis was following the standard
practice.

        A property technician “closed out” Vial Two’s control number in the ACE
property data management system, because it was understood that Vial Two would be
stored at the ISDOT and not return to the IMPD Property Room as per standard practice.

                                      Page 4 of 16
On or about August 9, 2010, Deputy Prosecutor Denise Robinson, of the Marion
County Prosecutor’s Office, assigned to the Bisard prosecution asked Sgt. Heustis to
retrieve Vial Two from ISDOT and return it to the IMPD Property Room. On August 12,
2010, Deputy Prosecutor Ed Zych wrote an email to Dr. Wu at the ISDOT, stating that
Sgt. Heustis “will be stopping by to pick the sample up and return it to the IMPD
Property Room.” Sgt. Heustis was copied on the email. The existing standard practice
was that once evidence, like blood samples, were delivered to the ISDOT then this
evidence would not be returned to the IMPD property room.1 Sgt. Heustis did not inform
the prosecutors that their request was contrary to standard practice. Sgt. Heustis did not
inform his supervisors about the request to move Vial Two.

       On August 12, 2010, Judge Grant Hawkins granted a defense motion to preserve
and maintain the evidence in the Bisard case. Judge Hawkins ordered that “any agency
that may have relevant and tangible evidence preserve and maintain said evidence for
possible testing and inspection by the defense at a later date.” The Order included all
blood samples taken from Bisard and Bisard’s squad car in use at the time of the
incident.” (State v. Bisard, Order dated August 12, 2010).

       On August 12, 2010, at 1:30 p.m., Sgt. Heustis sent an email to the day shift
supervisor in IMPD’s Property Room, asking her to preserve Vial One in the refrigerator
when Vial One was returned from the Crime lab. Sgt. Heustis wrote “we are under court
order to preserve all evidence in this case.” Sgt. Heustis, however, did not provide the
IMPD property room with a copy of the Court Order. Sgt. Heustis did not advise his
immediate supervisors about the Court's Preservation Order. On August 12, 2010, Vial
Two was still in storage at ISDOT. Sgt. Heustis did not send the Court preservation
Order to the ISDOT or otherwise inform them of the Court Order.

       On August 23, 2010, DC Cunningham instructed Lieutenant Pauli Irwin to
preserve the Bisard evidence after she learned about the Court Order issued by Judge
Hawkins from news reports.2 DC Cunningham also instructed Lt. Irwin that she, DC
Cunningham, had to authorize any activity regarding the Bisard evidence. DC
Cunningham told investigators that Lt. Irwin, in turn, instructed Property Room Manager
Theresa Bockbrader to place a “hold”3 on the Bisard evidence. The documents reviewed
confirmed Bockbrader made an entry into ACE, and changed the responsible officer for
the Bisard evidence to DC Cunningham. A note with DC Cunningham’s order was placed

1
  This is because as a state agency, the ISDOT is a different jurisdiction than Marion County.
2
  Lieutenant Irwin was placed in charge of citizen services in August 2010, after the Bisard accident. Lt.
Irwin’s areas of responsibility included the Citizen’s Service Desk, Auto Desk, Data Transcription, Property
Room/Annex, Latent Prints, Identification and Records, Criminal Records, Firearms and Alarm Citations.
When interviewed, Lt. Irwin advised that she was unfamiliar with IMPD Property Room General Orders or
operating procedures and was not trained in evidence handling, property room management, or on how to
preserve forensic evidence, such as blood evidence.
3
    We note that the term “hold” is a generic term used by the property room under a variety of
    circumstances. The term “hold” did not adequately convey that the IMPD was under a court order to
    preserve and maintain the evidence/property.

                                              Page 5 of 16
directly on the outside of the evidence envelope that contained Vial One. This note was
still attached to Vial One's evidence envelope when this investigation began on April 16,
2012.4




        On August 25, 2010, Sgt. Heustis retrieved Vial Two from ISDOT and returned it
to the IMPD Property Room in new packaging -- an unmarked Styrofoam container with
a rubber band around the container’s exterior.5 Initially, the Styrofoam container did not
have any exterior marking. The blood evidence vial, Vial Two, stored inside the
Styrofoam container still had the original marking. Sgt. Heustis handed the unmarked
Styrofoam container to Property Room Technician Rebecca Hardin. Since there was no
protocol or standard operating procedure to re-enter a piece of evidence after it has been
closed out of ACE, Rebecca Hardin treated the Styrofoam container and its contents as if
it was a new property item. Accordingly, Vial Two was assigned the control number “AC
10016631” and case number “DP10114281 (the Bisard case number).” Hardin generated
a computerized label and placed it on the top of the Styrofoam container.6




4
 It should be noted that on August 23, 2010, Vial Two remained logged out of the IMPD property
management data base and was still at the ISDOT.
5
  Per the practice that has been followed since the merger, blood vials transferred to ISDOT are not
returned to the IMPD property room. Instead, the ISDOT secures the blood samples or other evidence in its
facility until the case is fully adjudicated.
6
  The property room did not re-assign the evidence control number pertaining to items of evidence in the
    Bisard case, AC#10015325. Vial Two was re-entered into the system as a “new” item – and not
    returned to the list of Bisard evidence.

                                             Page 6 of 16
The Styrofoam container was then placed inside an 81/2 by 11 standard manila
mailing envelope because it was too large to fit into the standard evidence envelope used
to store blood vials. An adhesive label was secured to the outside of the envelope that
bore a bar code, the AC number, and Bisard’s case number. Officer Bisard’s name was
not written on the manila envelope or printed out on the external label. The exterior of
the manila envelope was also missing other important data normally found on IMPD
evidence envelopes such as: the invesitgator’s/officer’s “initials,” “Time recovered,”
Recovered at/From,” and an adequate description of the contents. This is the label placed
on the manila envelope.




                                      Page 7 of 16
This is the front of the manila envelope. As explained below, the handwritten note
was added on April 16, 2012.




                               Page 8 of 16
This is the back of the manila envelope as it appeared on April 16, 2012.

        Sgt. Heustis’ initials are not on the evidence seal. Instead the initials SLVS with
the date 9/23/2010 are on the evidence seal, which was not the date that Sgt. Heustis
returned the blood vial. The investigation determined these are the initials of Sgt. Sandy
Storkman. The Property Room Technician secured Vial Two in a refrigerated unit. Due
to the size of the envelope, Vial Two was not placed into the box where other blood vials
were stored. The storage box for blood vials is shown below.

        As a result of the following factors: a different AC number from Vial One, a
different type and size storage container than the one normally used for blood evidence
(plain manila envelope vs IMPD evidence envelope), the absence of markings to “hold”
the evidence, no mention of the Court Order, and no clear markings indicating that the
envelope contained Bisard evidence – Vial Two was not adequately identified or linked
with the Bisard case.




                                       Page 9 of 16
Sgt. Heustis completed a “Property Room Voucher” pertaining to Vial Two. A
Property Room Voucher is a document completed by persons requesting that property be
secured in the Property Room. The data fields include a description of the property, the
case number, and whether the item should be “held” or released. Sgt. Heustis did not
write that Judge Hawkins’ Court Order required that Vial Two be preserved and
maintained. Sgt. Heustis placed a “hold” on Vial Two. Sgt. Heustis did not write
“Bisard” on the property room voucher to make it clear that the blood sample was part of
the Bisard case. No one entered into ACE a note that an item of evidence known in the
system as “AC# 10016631” was subject to either the Court’s preservation Order, DC
Cunningham’s directive, or that it was Brisard’s blood.

      On August 26, 2010, Beth Dale, an attorney with the Office of Corporation
Counsel, emailed then Chief Ciesielski that a Court Order had been issued to preserve
and maintain the Bisard evidence. Chief Ciesielski notified Deputy Chief Cunningham.
This was the first time IMPD Command staff was formally notified of the Court Order.

        On September 2, 2010, DC Cunningham notified Sgt. Heustis by e-mail of the
Court Order. Sgt. Heustis replied to Deputy Chief Cunningham’s email that Vial Two had
been returned to the IMPD Property Room from ISDOT and that it was secured in the
refrigerator.

        On November 3, 2011, Property Room day shift supervisor Stacey Krom
transferred Vial Two from the IMPD Property Room to Property Annex J. Vial Two was
among other blood samples and forensic evidence transferred to the Annex because the
refrigerators were too full to hold all of the evidence. A picture of the current Property
Room refrigerators is below.



                                      Page 10 of 16
Ms. Krom ran a report to identify evidence that had been in the refrigerator more
than one year. Ms Krom obtained the data by searching ACE by AC number. Ms. Krom
ran AC numbers, because the AC numbers identified the date the property was checked
into the property room for refrigeration. Ms. Krom removed the oldest blood vials. Ms.
Krom did not recognize that Vial Two was part of the Bisard Case for the following
reasons: 1) Vial Two was assigned an AC number different from the Bisard case AC
number; 2) the manila envelope containing Vial Two was not marked with the name
“Bisard,” or with a directive to “hold” the property, or with a copy of the Court Order.

        Ms. Krom was not required to, nor did she cross-check, the AC number with the
case number to determine whether the case was open or closed, nor did she check the
JUSTIS system, or consult with the case investigator/officer to determine the status of the
investigation or court proceedings. There are no written protocols or standard operating
procedures to govern the transfer of refrigerated evidence into non-refrigerated storage.
Ms. Krom advised that she relied on an informal and unwritten policy developed by
Property Room Manager Theresa Bockbrader7 to determine when blood evidence could
be removed from refrigeration and transferred to the Property Room Annex.
        7
          Ms. Bockbrader has been the civilian manager of the Property Room since 2008. At the time of
her appointment, Bockbrader had served the IMPD for many years, but did not have experience in evidence
handling or property room management. Neither Bockbrader nor any of the employees in the Property
Room have received training in property room management, evidence handling and preservation.
Bockbrader learned how to perform her responsibilities from the property room employees she supervised.

                                           Page 11 of 16
Ms. Bockbrader informed the investigators that because there were no written
SOP’s she had to create her own solutions to solve operational issues that arose in the
IMPD Property Room. Because the Property Room did not have adequate space to store
blood vials and other items requiring refrigeration, in 2009, Ms. Bockbrader developed
an informal and unwritten policy regarding the storage of blood vials older than one year.
Ms. Bockbrader decided that blood vials older than one year could be transferred to non-
refrigerated storage in the Property Annex. Ms. Bockbrader implemented the policy after
consulting FSA and a toxicology professor at a local university Ms. Bockbrader’s
decision, though well-intended, was not factually or scientifically consistent with the
advice she received from FSA or the university professor, nor was it reviewed or
approved by IMPD personnel in her chain of command.

        On April 4, 2012 at 8:00 a.m., in preparation for the State’s motion to test Vial
Two and retest Vial One, DPs Hirshauer and Robinson met with Sgt. Heustis. Again, a
routine request was made by DP Robinson to Sgt. Heustis to make sure both Vials of
blood were packaged together in preparation for shipping to an independent lab in Texas,
if the court allowed the requested new testing. Sgt. Heustis and DP Hirschauer went to
the property room in the city/county building and requested information on Vial Two. A
Chain of Custody Report was printed at 0934 hours for blood stored under the DP
10114281 agency case number. DP Robinson was informed that Vial Two is in a
“wharehouse.” She was immediately concerned about the integrity of Vial Two and
requested it be returned to the property room downtown.

        In his interview with investigators, Sgt. Heustis described events from April 4,
2012:

        Ellen Corcella:      Okay. I just want to go back to another point where he says
                             who understood it was a very unfortunate event?

        Sgt. Heustis:        Well I did. I know Tom Hirshauer did.           Both of us
                             understood that.

        Ellen Corcella:      And did you convey that to anybody?

        Sgt. Heustis:        To Denise and to Becky.

        Ellen Corcella:      Okay.

        Sgt. Heustis:        I mean, we obviously conveyed it to Denise that the blood
                             had been moved, I mean she understood obviously what
                             that meant and

        Ellen Corcella:      That meant it was not refrigerated?




                                      Page 12 of 16
Sgt. Heustis:        Well that it had been out at the annex, yes. At that point,
                            okay, I was pretty sure that it had not been refrigerated in
                            the annex. Having been in the department for a while, and
                            having in my job you know evidence and stuff, I have been
                            out to the annex and I never observed refrigeration out
                            there. But I could not say with certainty that there was no
                            refrigeration out there or whether that blood had not be
                            refrigerated. I didn’t think it had, so at some point
                            subsequent to that I can’t remember exactly what day it
                            was, I spoke with I think it was Stacey Krom because she,
                            I’d asked Becky if anybody knew about the annex out there
                            and she said Stacey had worked out there. So I spoke with
                            Stacey and she confirm that no, the blood at the annex is not
                            refrigerated.   But I passed that on to Denise, that
                            confirmation, I mean I had told her already I didn’t think it
                            was but that was the confirmation.



The chain of custody report shows that Vial Two remained at Annex J, until April 5,
2012, when the property room transferred Vial Two back into the refrigerator in the main
Property Room. On April 6, 2012 Manager Bockbrader, stapled a note on Vial Two’s
manila envelope directing that Vial Two should remain refrigerated.




                                     Page 13 of 16
On April 11, 2012, according to DP Robinson, she learned that Vial Two may have
not been maintained in a refrigeratored environment at the Annex. According to DP
Robinson, this information was from officers not affiliated with the Bisard case or with
any other cases specifically involving blood vials.

       On April 12, 2012, Vicki Coates from the Marion County Prosecutor’s Office
spoke to Donna Forbes, then Chief Ciesielski’s assistant, to set up a meeting with the
Chief for Monday, April 16, 2012. Ms. Forbes, in turn, confirmed the time and date of
the meeting through Microsoft Outlook.

       On Monday, April 16, 2012 at 0716 hrs Sgt. Heustis confirms in an email to DP
Robinson, “Authority of the Property Room supervisor, there is no refrigerated storage
for any evidence at the Property Room annex at 901 N. Post Rd.”

       On April 16, 2012, at 8:00 a.m., Ciesielski met with Prosecutor Curry and DP
Denise Robinson. Prosecutor Curry advised Ciesielski that Vial Two had been removed
from refrigeration and transferred to Property Annex J. Prosecutor Curry provided
Ciesielski with the chain of custody reports for Vial One and Vial Two. The chain of
custody report for Vial Two documented the transfer of Vial Two to the Property Annex.




                                     Page 14 of 16
III.   CONCLUSIONS and RECOMMENDATIONS

        For purposes of this report, we make the observation that from day one – August
6, 2010 – the IMPD was on fair notice that it was – and is –important to handle the Bisard
case, and the evidence associated with it, with meticulous care and impeccable
professionalism. As identified herein, a series of missteps led to the placement of Vial
Two in unrefrigerated storage for approximately twenty-two weeks. Despite these
missteps, the integrity of Vial Two as the container for Bisard’s blood has not been
compromised. Bisard’s blood sample is in the original vial. The vial has never been
opened and the blood has never been tested. It is not within the purview of this
investigation to determine whether or not the lack of refrigeration compromised the
viability of the blood sample for alcohol or other testing. The viability of this test sample
must be determined through proper scientific analysis.

       This investigation also revealed there are significant administrative, supervisory,
and operational issues regarding IMPD’s evidence and property management. IMPD
operates five separate property/evidence facilities, many of which are in disrepair. There
is no differentiation between the way evidence and non-evidentiary property is stored.
The Property Room General Orders and procedures are out-of-date. In many cases, there
are no standard operating procedures. For example, the Property Room does not have
protocols for storing, handling and monitoring forensic evidence (eg. blood evidence).
Civilian staff is not appropriately supervised by IMPD command personnel. Neither
IMPD sworn nor civilian personnel are trained to perform their duties and
responsibilities.

        Sgt Heustis did not take sufficient steps to ensure the Bisard evidence was
properly secured. Sgt. Heustis retrieved Vial Two from the ISDOT even though this was
contrary to routine practice and had never been done before. He did not seek the advice
of his superior officers as to handle the situation, nor did he inform the MCPO that
returning Vial Two to the Property Room was inconsistent with standard operating
procedures. Sgt. Heustis’ delay in retrieving the evidence – from August 12, 2010 to
August 25, 2010 – contributed to the problem. Had Sgt. Heustis retrieved Vial Two on or
about August 12, 2010, Vial Two would have been in the IMPD Property Room on
August 23, 2010, when DC Cunningham secured the Bisard evidence in compliance with
the Court’s Order. When he returned Vial Two, Sgt. Heustis did not tell Lt. Irwin, his
immediate supervisors, or other pertinent persons about retrieving this piece of Bisard
evidence from ISDOT. At no time did Sgt. Heustis inform his chain of command and/or
Property Room staff that Judge Hawkins’ had issued a Court Order to preserve and
maintain the Bisard evidence. Sgt. Heustis never advised his chain of command that Vial
Two had been removed from refrigeration, transferred to Property Annex J, or returned to
the refrigeration in the Property Room. In essence, Sgt, Heustis kept his chain of
command in the dark regarding Vial Two.




                                       Page 15 of 16
Since April 16, 2012, the IMPD has undertaken a review of the IMPD Property
Room and its operations. The IMPD is developing new General Orders as well as Rules
and Regulations concerning evidence handling and property management. Additional
recommendations regarding property room operations and management will be
forthcoming in a separate report.




                                   Page 16 of 16

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Fbi bisard vial

  • 1. THE BISARD EVIDENCE BISARD’S BLOOD SAMPLE – VIAL TWO Prepared By: Ellen M. Corcella. Esq. Chief, Professional Standards Division Department of Public Safety Assigned investigators: Sgt. Dawn Higgins and Detective Michele Rusk of the Professional Standards Division, Department of Public Safety.
  • 2. I. INTRODUCTION. On August 6, 2010 Officer David Bisard, a sworn police officer for the Indianapolis Metropolitan Police Department (IMPD), was involved in a fatal crash while on duty. As part of the initial crash investigation, two vials of blood were drawn from Officer Bisard. The vials of blood are referred to herein as Vial One and Vial Two. Officer Bisard is currently facing criminal charges as a result of this crash in The State of Indiana v. David Bisard, Cause No. 49G051101FB002516 (hereinafter the “Bisard Case”). On April 16, 2012 at 8:00a.m., Marion County Prosecutor Terry Curry informed then IMPD Chief of Police Paul Ciesielski that one of the two blood samples drawn from David Bisard, commonly referred to as “Vial Two” was not stored in a refrigerated unit for a period of time. The prosecutor gave Ciesielski a chain of custody report for Vial One and Vial Two that demonstrated Vial Two had been in unrefrigerated storage. Chief Ciesielski notified Director of Public Safety Frank Straub. Director Straub, in turn, asked Ellen Corcella, Chief of Professional Standards, to determine the circumstances that caused Vial Two to be held in non-refrigerated storage. As part of the investigation, all civilian and sworn personnel involved were interviewed and all relevant documents reviewed. a. Summary of Factual Findings The investigation found that Vial Two was maintained and preserved in the IMPD’s refrigerated storage from on or about August 6, 2010 until August 9, 2010. On August 9, 2010, Vial Two was transferred to the Indiana State Department of Toxicology (“ISDOT”), where it was maintained in refrigerated storage. On August 25, 2010, Vial Two was retrieved from the ISDOT and returned to refrigerated storage in the IMPD Property Room. On November 3, 2011, Vial Two was transferred to Property Room Annex J where it was stored without refrigeration until April 5, 2012. Since April 5, 2012, Vial Two has been stored in refrigeration in the IMPD’s Property Room. At no time between August 6, 2010 and the present was the vial cap securing the blood sample within Vial Two ever removed. Vial Two’s seal remains intact. b. Summary of Conclusions A lack of clear policies and procedures, inadequate supervision, and a failure to properly safeguard the Brisard evidence ultimately led to Vial Two being removed from refrigeration in the Property Room and transferred to a non-refrigerated location in Property Annex J. The IMPD Property Room does not have procedures or policies for many of its primary duties and responsibilities. There are no storage or handling protocols for blood evidence. To the extent that policies and procedures exist, they are outdated, poorly constructed, and do not provide adequate guidance or protocols for the demands placed on IMPD property room personnel. Direct responsibility for the operation of the IMPD Property Room is placed in the hands of civilian personnel. The IMPD command staff does not provide sufficient oversight of the Property Room. Page 2 of 16
  • 3. Neither the Property Room’s civilian personnel nor its IMPD commander were properly trained in evidence handling or in property room management. They have not been trained in the proper storage protocols for blood evidence. As a result of these gaps in existing systems, policies and supervision, Vial Two was improperly transferred to unrefrigerated storage in Property Annex J. Page 3 of 16
  • 4. II. STATEMENT OF FACTS On August 6, 2010, Lt. Stan Stephens of the Lawrence Police Department, and a member of the Fatal Accident Team (FAT), placed two vials of blood in the IMPD Property Room under IMPD Case # DP100114281. These vials contained blood drawn from IMPD Officer David Bisard, who had been involved in a fatal crash earlier in the day. When Lt. Stephens turned the two blood vials into the IMPD Property Room, the vials, along with other evidence collected in the Bisard matter, were assigned control number “AC 10015325” and case number “DP10114281.” It is standard procedure to draw two vials of blood. Vial Two was placed into a manila evidence envelope as is the protocol for packaging blood vials for evidence. The standard evidence envelope used by the property room is shown in the photograph below: Standard evidence envelope used to store blood vials. On August 9, 2010, at about 3:14 p.m., IMPD Sgt. Douglas Heustis retrieved numerous blood samples from the IMPD Property Room, including Bisard's blood sample contained in Vial Two. Vial Two was in a standard evidence envelope. Sgt. Heustis transported the blood vials to the ISDOT. Sgt. Heustis has been assigned the task of transporting blood vials to the ISDOT since approximately 2007. According to all parties with experience in handling blood evidence related to Operating Motor Vehicle While Intoxicated (OVWI) cases, one blood vial is routinely tested by the Indianapolis- Marion County Forensic Services Agency (FSA) for blood alcohol content (BAC). The second blood vial is transported to the Indiana State Department of Toxicology (ISDOT) where it is tested for the presence of drugs. Sgt. Heustis was following the standard practice. A property technician “closed out” Vial Two’s control number in the ACE property data management system, because it was understood that Vial Two would be stored at the ISDOT and not return to the IMPD Property Room as per standard practice. Page 4 of 16
  • 5. On or about August 9, 2010, Deputy Prosecutor Denise Robinson, of the Marion County Prosecutor’s Office, assigned to the Bisard prosecution asked Sgt. Heustis to retrieve Vial Two from ISDOT and return it to the IMPD Property Room. On August 12, 2010, Deputy Prosecutor Ed Zych wrote an email to Dr. Wu at the ISDOT, stating that Sgt. Heustis “will be stopping by to pick the sample up and return it to the IMPD Property Room.” Sgt. Heustis was copied on the email. The existing standard practice was that once evidence, like blood samples, were delivered to the ISDOT then this evidence would not be returned to the IMPD property room.1 Sgt. Heustis did not inform the prosecutors that their request was contrary to standard practice. Sgt. Heustis did not inform his supervisors about the request to move Vial Two. On August 12, 2010, Judge Grant Hawkins granted a defense motion to preserve and maintain the evidence in the Bisard case. Judge Hawkins ordered that “any agency that may have relevant and tangible evidence preserve and maintain said evidence for possible testing and inspection by the defense at a later date.” The Order included all blood samples taken from Bisard and Bisard’s squad car in use at the time of the incident.” (State v. Bisard, Order dated August 12, 2010). On August 12, 2010, at 1:30 p.m., Sgt. Heustis sent an email to the day shift supervisor in IMPD’s Property Room, asking her to preserve Vial One in the refrigerator when Vial One was returned from the Crime lab. Sgt. Heustis wrote “we are under court order to preserve all evidence in this case.” Sgt. Heustis, however, did not provide the IMPD property room with a copy of the Court Order. Sgt. Heustis did not advise his immediate supervisors about the Court's Preservation Order. On August 12, 2010, Vial Two was still in storage at ISDOT. Sgt. Heustis did not send the Court preservation Order to the ISDOT or otherwise inform them of the Court Order. On August 23, 2010, DC Cunningham instructed Lieutenant Pauli Irwin to preserve the Bisard evidence after she learned about the Court Order issued by Judge Hawkins from news reports.2 DC Cunningham also instructed Lt. Irwin that she, DC Cunningham, had to authorize any activity regarding the Bisard evidence. DC Cunningham told investigators that Lt. Irwin, in turn, instructed Property Room Manager Theresa Bockbrader to place a “hold”3 on the Bisard evidence. The documents reviewed confirmed Bockbrader made an entry into ACE, and changed the responsible officer for the Bisard evidence to DC Cunningham. A note with DC Cunningham’s order was placed 1 This is because as a state agency, the ISDOT is a different jurisdiction than Marion County. 2 Lieutenant Irwin was placed in charge of citizen services in August 2010, after the Bisard accident. Lt. Irwin’s areas of responsibility included the Citizen’s Service Desk, Auto Desk, Data Transcription, Property Room/Annex, Latent Prints, Identification and Records, Criminal Records, Firearms and Alarm Citations. When interviewed, Lt. Irwin advised that she was unfamiliar with IMPD Property Room General Orders or operating procedures and was not trained in evidence handling, property room management, or on how to preserve forensic evidence, such as blood evidence. 3 We note that the term “hold” is a generic term used by the property room under a variety of circumstances. The term “hold” did not adequately convey that the IMPD was under a court order to preserve and maintain the evidence/property. Page 5 of 16
  • 6. directly on the outside of the evidence envelope that contained Vial One. This note was still attached to Vial One's evidence envelope when this investigation began on April 16, 2012.4 On August 25, 2010, Sgt. Heustis retrieved Vial Two from ISDOT and returned it to the IMPD Property Room in new packaging -- an unmarked Styrofoam container with a rubber band around the container’s exterior.5 Initially, the Styrofoam container did not have any exterior marking. The blood evidence vial, Vial Two, stored inside the Styrofoam container still had the original marking. Sgt. Heustis handed the unmarked Styrofoam container to Property Room Technician Rebecca Hardin. Since there was no protocol or standard operating procedure to re-enter a piece of evidence after it has been closed out of ACE, Rebecca Hardin treated the Styrofoam container and its contents as if it was a new property item. Accordingly, Vial Two was assigned the control number “AC 10016631” and case number “DP10114281 (the Bisard case number).” Hardin generated a computerized label and placed it on the top of the Styrofoam container.6 4 It should be noted that on August 23, 2010, Vial Two remained logged out of the IMPD property management data base and was still at the ISDOT. 5 Per the practice that has been followed since the merger, blood vials transferred to ISDOT are not returned to the IMPD property room. Instead, the ISDOT secures the blood samples or other evidence in its facility until the case is fully adjudicated. 6 The property room did not re-assign the evidence control number pertaining to items of evidence in the Bisard case, AC#10015325. Vial Two was re-entered into the system as a “new” item – and not returned to the list of Bisard evidence. Page 6 of 16
  • 7. The Styrofoam container was then placed inside an 81/2 by 11 standard manila mailing envelope because it was too large to fit into the standard evidence envelope used to store blood vials. An adhesive label was secured to the outside of the envelope that bore a bar code, the AC number, and Bisard’s case number. Officer Bisard’s name was not written on the manila envelope or printed out on the external label. The exterior of the manila envelope was also missing other important data normally found on IMPD evidence envelopes such as: the invesitgator’s/officer’s “initials,” “Time recovered,” Recovered at/From,” and an adequate description of the contents. This is the label placed on the manila envelope. Page 7 of 16
  • 8. This is the front of the manila envelope. As explained below, the handwritten note was added on April 16, 2012. Page 8 of 16
  • 9. This is the back of the manila envelope as it appeared on April 16, 2012. Sgt. Heustis’ initials are not on the evidence seal. Instead the initials SLVS with the date 9/23/2010 are on the evidence seal, which was not the date that Sgt. Heustis returned the blood vial. The investigation determined these are the initials of Sgt. Sandy Storkman. The Property Room Technician secured Vial Two in a refrigerated unit. Due to the size of the envelope, Vial Two was not placed into the box where other blood vials were stored. The storage box for blood vials is shown below. As a result of the following factors: a different AC number from Vial One, a different type and size storage container than the one normally used for blood evidence (plain manila envelope vs IMPD evidence envelope), the absence of markings to “hold” the evidence, no mention of the Court Order, and no clear markings indicating that the envelope contained Bisard evidence – Vial Two was not adequately identified or linked with the Bisard case. Page 9 of 16
  • 10. Sgt. Heustis completed a “Property Room Voucher” pertaining to Vial Two. A Property Room Voucher is a document completed by persons requesting that property be secured in the Property Room. The data fields include a description of the property, the case number, and whether the item should be “held” or released. Sgt. Heustis did not write that Judge Hawkins’ Court Order required that Vial Two be preserved and maintained. Sgt. Heustis placed a “hold” on Vial Two. Sgt. Heustis did not write “Bisard” on the property room voucher to make it clear that the blood sample was part of the Bisard case. No one entered into ACE a note that an item of evidence known in the system as “AC# 10016631” was subject to either the Court’s preservation Order, DC Cunningham’s directive, or that it was Brisard’s blood. On August 26, 2010, Beth Dale, an attorney with the Office of Corporation Counsel, emailed then Chief Ciesielski that a Court Order had been issued to preserve and maintain the Bisard evidence. Chief Ciesielski notified Deputy Chief Cunningham. This was the first time IMPD Command staff was formally notified of the Court Order. On September 2, 2010, DC Cunningham notified Sgt. Heustis by e-mail of the Court Order. Sgt. Heustis replied to Deputy Chief Cunningham’s email that Vial Two had been returned to the IMPD Property Room from ISDOT and that it was secured in the refrigerator. On November 3, 2011, Property Room day shift supervisor Stacey Krom transferred Vial Two from the IMPD Property Room to Property Annex J. Vial Two was among other blood samples and forensic evidence transferred to the Annex because the refrigerators were too full to hold all of the evidence. A picture of the current Property Room refrigerators is below. Page 10 of 16
  • 11. Ms. Krom ran a report to identify evidence that had been in the refrigerator more than one year. Ms Krom obtained the data by searching ACE by AC number. Ms. Krom ran AC numbers, because the AC numbers identified the date the property was checked into the property room for refrigeration. Ms. Krom removed the oldest blood vials. Ms. Krom did not recognize that Vial Two was part of the Bisard Case for the following reasons: 1) Vial Two was assigned an AC number different from the Bisard case AC number; 2) the manila envelope containing Vial Two was not marked with the name “Bisard,” or with a directive to “hold” the property, or with a copy of the Court Order. Ms. Krom was not required to, nor did she cross-check, the AC number with the case number to determine whether the case was open or closed, nor did she check the JUSTIS system, or consult with the case investigator/officer to determine the status of the investigation or court proceedings. There are no written protocols or standard operating procedures to govern the transfer of refrigerated evidence into non-refrigerated storage. Ms. Krom advised that she relied on an informal and unwritten policy developed by Property Room Manager Theresa Bockbrader7 to determine when blood evidence could be removed from refrigeration and transferred to the Property Room Annex. 7 Ms. Bockbrader has been the civilian manager of the Property Room since 2008. At the time of her appointment, Bockbrader had served the IMPD for many years, but did not have experience in evidence handling or property room management. Neither Bockbrader nor any of the employees in the Property Room have received training in property room management, evidence handling and preservation. Bockbrader learned how to perform her responsibilities from the property room employees she supervised. Page 11 of 16
  • 12. Ms. Bockbrader informed the investigators that because there were no written SOP’s she had to create her own solutions to solve operational issues that arose in the IMPD Property Room. Because the Property Room did not have adequate space to store blood vials and other items requiring refrigeration, in 2009, Ms. Bockbrader developed an informal and unwritten policy regarding the storage of blood vials older than one year. Ms. Bockbrader decided that blood vials older than one year could be transferred to non- refrigerated storage in the Property Annex. Ms. Bockbrader implemented the policy after consulting FSA and a toxicology professor at a local university Ms. Bockbrader’s decision, though well-intended, was not factually or scientifically consistent with the advice she received from FSA or the university professor, nor was it reviewed or approved by IMPD personnel in her chain of command. On April 4, 2012 at 8:00 a.m., in preparation for the State’s motion to test Vial Two and retest Vial One, DPs Hirshauer and Robinson met with Sgt. Heustis. Again, a routine request was made by DP Robinson to Sgt. Heustis to make sure both Vials of blood were packaged together in preparation for shipping to an independent lab in Texas, if the court allowed the requested new testing. Sgt. Heustis and DP Hirschauer went to the property room in the city/county building and requested information on Vial Two. A Chain of Custody Report was printed at 0934 hours for blood stored under the DP 10114281 agency case number. DP Robinson was informed that Vial Two is in a “wharehouse.” She was immediately concerned about the integrity of Vial Two and requested it be returned to the property room downtown. In his interview with investigators, Sgt. Heustis described events from April 4, 2012: Ellen Corcella: Okay. I just want to go back to another point where he says who understood it was a very unfortunate event? Sgt. Heustis: Well I did. I know Tom Hirshauer did. Both of us understood that. Ellen Corcella: And did you convey that to anybody? Sgt. Heustis: To Denise and to Becky. Ellen Corcella: Okay. Sgt. Heustis: I mean, we obviously conveyed it to Denise that the blood had been moved, I mean she understood obviously what that meant and Ellen Corcella: That meant it was not refrigerated? Page 12 of 16
  • 13. Sgt. Heustis: Well that it had been out at the annex, yes. At that point, okay, I was pretty sure that it had not been refrigerated in the annex. Having been in the department for a while, and having in my job you know evidence and stuff, I have been out to the annex and I never observed refrigeration out there. But I could not say with certainty that there was no refrigeration out there or whether that blood had not be refrigerated. I didn’t think it had, so at some point subsequent to that I can’t remember exactly what day it was, I spoke with I think it was Stacey Krom because she, I’d asked Becky if anybody knew about the annex out there and she said Stacey had worked out there. So I spoke with Stacey and she confirm that no, the blood at the annex is not refrigerated. But I passed that on to Denise, that confirmation, I mean I had told her already I didn’t think it was but that was the confirmation. The chain of custody report shows that Vial Two remained at Annex J, until April 5, 2012, when the property room transferred Vial Two back into the refrigerator in the main Property Room. On April 6, 2012 Manager Bockbrader, stapled a note on Vial Two’s manila envelope directing that Vial Two should remain refrigerated. Page 13 of 16
  • 14. On April 11, 2012, according to DP Robinson, she learned that Vial Two may have not been maintained in a refrigeratored environment at the Annex. According to DP Robinson, this information was from officers not affiliated with the Bisard case or with any other cases specifically involving blood vials. On April 12, 2012, Vicki Coates from the Marion County Prosecutor’s Office spoke to Donna Forbes, then Chief Ciesielski’s assistant, to set up a meeting with the Chief for Monday, April 16, 2012. Ms. Forbes, in turn, confirmed the time and date of the meeting through Microsoft Outlook. On Monday, April 16, 2012 at 0716 hrs Sgt. Heustis confirms in an email to DP Robinson, “Authority of the Property Room supervisor, there is no refrigerated storage for any evidence at the Property Room annex at 901 N. Post Rd.” On April 16, 2012, at 8:00 a.m., Ciesielski met with Prosecutor Curry and DP Denise Robinson. Prosecutor Curry advised Ciesielski that Vial Two had been removed from refrigeration and transferred to Property Annex J. Prosecutor Curry provided Ciesielski with the chain of custody reports for Vial One and Vial Two. The chain of custody report for Vial Two documented the transfer of Vial Two to the Property Annex. Page 14 of 16
  • 15. III. CONCLUSIONS and RECOMMENDATIONS For purposes of this report, we make the observation that from day one – August 6, 2010 – the IMPD was on fair notice that it was – and is –important to handle the Bisard case, and the evidence associated with it, with meticulous care and impeccable professionalism. As identified herein, a series of missteps led to the placement of Vial Two in unrefrigerated storage for approximately twenty-two weeks. Despite these missteps, the integrity of Vial Two as the container for Bisard’s blood has not been compromised. Bisard’s blood sample is in the original vial. The vial has never been opened and the blood has never been tested. It is not within the purview of this investigation to determine whether or not the lack of refrigeration compromised the viability of the blood sample for alcohol or other testing. The viability of this test sample must be determined through proper scientific analysis. This investigation also revealed there are significant administrative, supervisory, and operational issues regarding IMPD’s evidence and property management. IMPD operates five separate property/evidence facilities, many of which are in disrepair. There is no differentiation between the way evidence and non-evidentiary property is stored. The Property Room General Orders and procedures are out-of-date. In many cases, there are no standard operating procedures. For example, the Property Room does not have protocols for storing, handling and monitoring forensic evidence (eg. blood evidence). Civilian staff is not appropriately supervised by IMPD command personnel. Neither IMPD sworn nor civilian personnel are trained to perform their duties and responsibilities. Sgt Heustis did not take sufficient steps to ensure the Bisard evidence was properly secured. Sgt. Heustis retrieved Vial Two from the ISDOT even though this was contrary to routine practice and had never been done before. He did not seek the advice of his superior officers as to handle the situation, nor did he inform the MCPO that returning Vial Two to the Property Room was inconsistent with standard operating procedures. Sgt. Heustis’ delay in retrieving the evidence – from August 12, 2010 to August 25, 2010 – contributed to the problem. Had Sgt. Heustis retrieved Vial Two on or about August 12, 2010, Vial Two would have been in the IMPD Property Room on August 23, 2010, when DC Cunningham secured the Bisard evidence in compliance with the Court’s Order. When he returned Vial Two, Sgt. Heustis did not tell Lt. Irwin, his immediate supervisors, or other pertinent persons about retrieving this piece of Bisard evidence from ISDOT. At no time did Sgt. Heustis inform his chain of command and/or Property Room staff that Judge Hawkins’ had issued a Court Order to preserve and maintain the Bisard evidence. Sgt. Heustis never advised his chain of command that Vial Two had been removed from refrigeration, transferred to Property Annex J, or returned to the refrigeration in the Property Room. In essence, Sgt, Heustis kept his chain of command in the dark regarding Vial Two. Page 15 of 16
  • 16. Since April 16, 2012, the IMPD has undertaken a review of the IMPD Property Room and its operations. The IMPD is developing new General Orders as well as Rules and Regulations concerning evidence handling and property management. Additional recommendations regarding property room operations and management will be forthcoming in a separate report. Page 16 of 16