As foundation for ‘excited delirium’ diagnosis cracks, fallout spreads

KFF Health NewsDec 13 2023

When Angelo Quinto's family learned that officials blamed his 2020 death on "excited delirium," a term they had never heard before, they couldn't believe it. To them, it was obvious the science behind the diagnosis wasn't real.

Quinto, 30, had been pinned on the ground for at least 90 seconds by police in California and stopped breathing. He died three days later.

Now his relatives are asking a federal judge to exclude any testimony about "excited delirium" in their wrongful death case against the city of Antioch. Their case may be stronger than ever.

Their push comes at the end of a pivotal year for the long-standing, nationwide effort to discard the use of excited delirium in official proceedings. Over the past 40 years, the discredited, racially biased theory has been used to explain away police culpability for many in-custody deaths. But in October, the American College of Emergency Physicians disavowed a key paper that seemingly gave it scientific legitimacy, and the College of American Pathologists said it should no longer be cited as a cause of death.

That same month, California's Democratic Gov. Gavin Newsom signed the nation's first law to ban the term "excited delirium" as a diagnosis and cause of death on death certificates, autopsy reports, and police reports. Legislators in other states are expected to consider similar bills next year, and some law enforcement agencies and training organizations have dropped references to excited delirium from their policy manuals and pulled back from training police on the debunked theory.

Despite all that momentum, families, attorneys, policing experts, and doctors say much remains to be done to correct the mistakes of the past, to ensure justice in ongoing trials, and to prevent avoidable deaths in the future. But after years of fighting, they're heartened to see any movement at all.

"This entire thing, it's a nightmare," said Bella Collins, Angelo's sister. "But there are silver linings everywhere, and I feel so fortunate to be able to see change happening."

Ultimately, the campaign against excited delirium seeks to transform the way police deal with people undergoing mental health crises.

"This is really about saving lives," said Joanna Naples-Mitchell, an attorney who worked on an influential Physicians for Human Rights review of excited delirium.

Changing law enforcement training

The use of the term "excited delirium syndrome" became pervasive after the American College of Emergency Physicians published a white paper on it in 2009. It proposed that individuals in a mental health crisis, often under the influence of drugs or alcohol, can exhibit superhuman strength as police try to control them, and then die suddenly from the condition, not the police response.

The ACEP white paper was significant in catalyzing police training and policy, said Marc Krupanski, director of criminal justice and policing at Arnold Ventures, one of the largest nonprofit funders of criminal justice policy. The theory contributed to deaths, he said, because it encouraged officers to apply greater force rather than call medical professionals when they saw people in aggressive states.

After George Floyd's 2020 death, which officers blamed on excited delirium, the American Medical Association and the American Psychiatric Association formally rejected it as a medical condition. Then came disavowals from the National Association of Medical Examiners and the emergency physicians' and pathologists' groups this year.

The moves by medical societies to renounce the term have already had tangible, albeit limited, effects. In November, Lexipol, a training organization used by thousands of public safety agencies in the U.S., reiterated its earlier move away from excited delirium, citing the California law and ACEP's retraction of the 2009 white paper.

Lexipol now guides officers to rely on what they can observe, and not to guess at a person's mental status or medical condition, said Mike Ranalli, a lawyer and police trainer with the Texas-based group. "If somebody appears to be in distress, just get the EMS," he said, referring to emergency medical services.

Patrick Caceres, a senior investigator at the Bay Area Rapid Transit's Office of the Independent Police Auditor, successfully pushed to remove excited delirium from the BART Police Department's policy manual after learning about Quinto's death in 2020 and seeing the American Medical Association's rejection of it the following year.

Caceres fears that rooting out the concept — not just the term — more broadly will take time in a country where law enforcement is spread across roughly 18,000 agencies governed by independent police chiefs or sheriffs.

"The kinds of training and the kinds of conversations that need to happen, we're still a long way away from that," said Caceres.

In Tacoma, Washington, where three police officers have been charged with the 2020 death of Manuel Ellis, The Seattle Times reported that local first responders testified as recently as October that they still "embrace" the concept.

But in Colorado, the state's Peace Officer Standards and Training board ruled on Dec. 1 to drop excited delirium training for new law enforcement officers, KUSA-TV reported.

And two Colorado lawmakers, Democratic state Reps. Judy Amabile and Leslie Herod, have drafted a bill for the 2024 legislative session banning excited delirium from other police and EMS training and prohibiting coroners from citing it as a cause of death.

"This idea that it gives you superhuman strength causes the police to think they should respond in a way that is often completely inappropriate for what's actually happening," Amabile said. "It just seems obvious that we should stop doing that."

She would like police to focus more on de-escalation tactics, and make sure 911 calls for people in mental health crisis are routed to behavioral health professionals who are part of crisis intervention teams.

Taking 'excited delirium' out of the equation

As the Quinto family seeks justice in the death of the 30-year-old Navy veteran, they are hopeful the new refutations of excited delirium will bolster their wrongful death lawsuit against the city of Antioch. On the other side, defense lawyers have argued that jurors should hear testimony about the theory.

On Oct. 26, the family cited both the new California law and the ACEP rebuke of the diagnosis when it asked a U.S. District Court judge in California to exclude witness testimony and evidence related to excited delirium, saying it "cannot be accepted as a scientifically valid diagnosis having anything to do with Quinto's death."

"A defense based on BS can succeed," family attorney Ben Nisenbaum said. "It can succeed by giving jurors an excuse to give the cops a way out of this."

Meanwhile, advocates are calling for a reexamination of autopsies of those who died in law enforcement custody, and families are fighting to change death certificates that blame excited delirium.

The Maryland attorney general's office is conducting an audit of autopsies under the tenure of former chief medical examiner David Fowler, who has attributed various deaths to excited delirium. But that's just one state reviewing a subset of its in-custody deaths.

The family of Alexander Rios, 28, reached a $4 million settlement with Richland County, Ohio, in 2021 after jail officers piled on Rios and shocked him until he turned blue and limp in September 2019. During a criminal trial against one of the officers that ended in a mistrial this November, the pathologist who helped conduct Rios' autopsy testified that her supervisor pressured her to list "excited delirium" as the cause of death even though she didn't agree. Still, excited delirium remains his official cause of death.

The county refused to update the record, so his relatives are suing to force a change to his official cause of death. A trial is set for May.

Changing the death certificate will be a form of justice, but it won't undo the damage his death has caused, said Don Mould, Rios' stepfather, who is now helping to raise one of Rios' three children.

"Here is a kid that's life is upside down," he said. "No one should go to jail and walk in and not be able to walk out."

In some cases, death certificates may be hard to refile. Quinto's family has asked a state judge to throw out the coroner's findings about his 2020 death. But the California law, which takes effect in January and bans excited delirium on death certificates, cannot be applied retroactively, said Contra Costa County Counsel Thomas Geiger in a court filing.

And, despite the 2023 disavowals by the main medical examiners' and pathologists' groups, excited delirium — or a similar explanation — could still show up on future autopsy reports outside California. No single group has authority over the thousands of individual medical examiners and coroners, some of whom work closely with law enforcement officials. The system for determining a cause of death is deeply disjointed and chronically underfunded.

"One of the unfortunate things, at least within forensic pathology, is that many things are very piecemeal," said Anna Tart, a member of the Forensic Pathology Committee of the College of American Pathologists. She said that CAP plans to educate members through conferences and webinars but won't discipline members who continue to use the term.

Justin Feldman, principal research scientist with the Center for Policing Equity, said that medical examiners need even more pressure and oversight to ensure that they don't find other ways to attribute deaths caused by police restraint to something else.

Only a minority of deaths in police custody now cite excited delirium, he said. Instead, many deaths are being blamed on stimulants, even though fatal cocaine or methamphetamine overdoses are rare in the absence of opioids.

Yet advocates are hopeful that this year marks enough of a turning point that alternative terms will have less traction.

The California law and ACEP decision take "a huge piece of junk science out of the equation," said Julia Sherwin, a California civil rights attorney who co-authored the Physicians for Human Rights report.

Sherwin is representing the family of Mario Gonzalez, who died in police custody in 2021, in a lawsuit against the city of Alameda, California. Excited delirium doesn't appear on Gonzalez's death certificate, but medical experts testifying for the officers who restrained him cited the theory in depositions.

She said she plans to file a motion excluding the testimony about excited delirium in that upcoming case and similar motions in all the restraint-asphyxia cases she handles.

"And, in every case, lawyers around the country should be doing that," Sherwin said.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.