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Medical Groups Disavow Discredited Excuse for Deaths in the Criminal Justice System

For decades, deaths in custody have been blamed on an unscientific diagnosis of excited delirium.” Now medical professionals, law enforcement agencies, and state legislatures are rejecting the term in hopes of improving policing.

Image of police officer restraining person.
(SimonSkafar/ Getty Images)

Angelo Quinto was experiencing a mental health crisis when his sister called 911 in 2020. By the time officers from the Antioch, California, police department arrived, Quinto’s mother had already subdued him. But officers nevertheless restrained the 30-year-old man, placed him on his stomach, and kneeled on him for more than five minutes. 

Quinto stopped breathing and became unresponsive. When paramedics arrived, they took him to the hospital where it was discovered that he had little brain activity. He was pronounced dead three days later.

To Quinto’s distraught family, it was clear that he had asphyxiated due to the officers’ restraint. But the coroner’s report determined his death to be the result of something called excited delirium,” a diagnosis that had been used increasingly in recent decades to explain how a person demonstrating agitation can die suddenly through no fault of police. Excited delirium” was also cited in the deaths of George Floyd in Minneapolis, Daniel Prude in Rochester, New York, and Elijah McClain in Aurora, Colorado. 

It’s very angering and frustrating,” says Bella Quinto Collins, Quinto’s sister.

Collins, her mother, and her father fought the official determination in court and they have spent the three years since then working to ban the use of the term excited delirium” in coroner’s reports. 

We have been fighting the entire time to see what semblance of justice we can get from the system,” says Robert Collins, Quinto’s stepfather. 

In recent years, the excited delirium” diagnosis has come under scrutiny as evidence has emerged that it has no scientific basis. In October 2023, the American College of Emergency Physicians (ACEP) removed approval for2009 position paper in which the organization endorsed the diagnosis, following similar moves by other national medical bodies. The move by ACEP made national headlines since it had been one of the last major medical associations to maintain support for the diagnosis.

Policing experts say that rejecting excited delirium” is an important step toward addressing the role of medical practitioners in police reform efforts. 

Policing needs to be evidence-based, and anything we do in terms of law enforcement policies and training should be based on evidence,” says Marc Krupanski, director of criminal justice for Arnold Ventures (AV). “‘Excited delirium’ is not.”

Policing needs to be evidence-based, and anything we do in terms of law enforcement policies and training should be based on evidence. Excited delirium is not.
Marc Krupanski director of criminal justice for Arnold Ventures

Krupanski explains that ending the use of the diagnosis would complement other police reform efforts nationally around improving de-escalation training and changing responses to mental and behavioral health crises, as well as increasing accountability when people die at the hands of law enforcement.

Removing this pseudo-science jargon should encourage law enforcement and other first responders to be much more careful about how they approach these situations,” Krupanski says.

A baseless diagnosis” 

A recent report from Physicians for Human Rights (PHR), the dissemination of which has been supported by AV, reviews the evidence behind so-called excited delirium syndrome,” ultimately debunking it as a baseless diagnosis.” 

The report explains that the term originated in the 1980s as part of forensic pathologists’ case reports on cocaine intoxication. It was used to describe a state of drug-related agitation in which a person may wield superhuman strength” and was at risk of sudden death. In the years that followed, a small number of medical experts — along with private firms, such as TASER International (now Axon Enterprise), the company that makes the brand of stun guns popular with law enforcement — disseminated and promoted the term, and served as repeat defense witnesses in cases of alleged police liability. 

Prominent medical organizations like ACEP and the National Association of Medical Examiners (NAME) also endorsed its use, and it gradually evolved into a catch-all concept that was offered in court cases to explain a wide range of instances in which people died in police custody after experiencing agitation, often while being restrained. Following the recognition by medical associations, police agencies began to set policies and training based on the diagnosis as well. 

The diagnosis, however, lacks a clear, consistent definition as well as a diagnostic standard, and is based on subjective descriptions, the PHR report notes. Its purported signs and symptoms vary considerably and could describe a number of different underlying medical conditions, explains Joanna Naples-Mitchell, a human rights lawyer and researcher who co-authored the report. Some of those symptoms have racist connotations, including the idea that a person, often a Black male, possesses superhuman strength” or is impervious to pain.” 

It’s a very amorphous concept,” Naples-Mitchell says. It has an extremely racist history, a racist application, and the actual definition is racist. So, it’s just problematic in every way.” 

Yet, according to the report, since 2010, at least 160 deaths in police custody have been officially attributed to excited delirium,” 56% of which involved Black or Latino people. A majority of those deaths involved some kind of force or restraint, particularly face-down restraint of the type that Angelo Quinto experienced.

number of deaths attributed to “excited delirium” while in police custody
percentage of “excited delirium” deaths that were people of Black or Latino descent

Medical organizations began backing away from the term excited delirium” in 2020 following outcry over the murder of George Floyd by a police officer. The American Medical Association and the American Psychiatric Association both rejected the term as nonmedical, noting the discriminatory manner in which it is used. After the publication of PHR’s report and sustained advocacy by PHR and others, NAME and ACEP followed. Medical professionals see ACEP’s October 2023 statement as the nail in the coffin for the diagnosis — although work remains to change the practices of police and medical examiners. 

We are now in a situation where there’s not a single major medical association in the United States that endorses excited delirium,’” Naples-Mitchell says. The last two major ones have explicitly said that their past publications are not valid anymore. So, this is a tremendous victory for all of the advocates who have been pushing for this for years, including impacted families.”

It was pretty emotionally traumatic”

The report and subsequent advocacy from PHR and its partners incorporate stories and contributions from families whose loved ones’ deaths were determined to be the result of excited delirium.” In addition to Angelo Quinto, this has included the case of Patrick Burns, an accountant for the state of Illinois. In 2010, Burns experienced an episode spurred by mental health issues and drug use that led neighbors to call the police. When police arrived, they hog-tied the 50-year-old man and shocked him with a Taser multiple times before he became unconscious and was brought to the hospital. He died a few days later. 

Based on Burns’s toxicology report, along with police accounts saying that he was out of control and impervious to cold weather, a coroner’s inquest ruled his death a textbook case” of excited delirium.” 

His brother, Richard Burns, has spent over a decade seeking to expose the misconduct that contributed to his brother’s death and the unscientific investigation that resulted in his brother’s officially listed cause of death.

I was the one who formally filed a wrongful death lawsuit against the county,” says Burns, 61. It was pretty emotionally traumatic for me that he had passed to begin with, and then on top of that I was told that he died of this bogus term and that the county was going to cover up and protect the police from accusations of excessive force.”

Due to Burns’s advocacy, his brother was the first in the nation to receive a new official death certificate from the county coroner’s office that removes the term excited delirium” and revises the manner of death from undetermined” to homicide.”

In addition to advocating for policy changes, Burns has formed a nonprofit, Truth in Death, and produced a forthcoming documentary film about his brother’s case. 

Making policing better”

Some law enforcement agencies have been proactive about ending their use of the term excited delirium.” In August 2023, the Bay Area Rapid Transit (BART) Police Department in California removed the term from its policy manual and issued a bulletin informing employees not to use the term in any written reports. 

Patrick Caceres, an investigator with the BART Office of the Independent Police Auditor, which has oversight authority of the BART Police Department, was instrumental in encouraging the policy change. 

Following the in-custody death of Angelo Quinto, Caceres researched the term and learned about medical associations’ rising opposition to its use. In his investigation, Caceres discovered that the BART police department had used the term around 10 times over the course of 2021 — never for a death in custody, but for narrative incident reports. He brought his concerns to the deputy chief of police and arranged a series of dialogues with the agency, sharing research that shows how using the language of excited delirium” could be more harmful than helpful. 

It didn’t add value to any of the police reports that I read,” Caceres says. And I raised the point that there is information, according to research, that this term is being coupled with racial bias and improper action taken by officers.” 

I raised the point that there is information, according to research, that this term is being coupled with racial bias and improper action taken by officers.
Patrick Caceres investigator with the BART Office of the Independent Police Auditor

The oversight agency recommended removing the term entirely from agency use, and the BART Police Department agreed. Together, they looked to the PHR report for guidance on how to make the change in their training, policies, and procedures. 

This work was founded in the desire to change disparate outcomes for Black and brown people in the justice system,” Caceres says. It’s meaningful, because it’s a way to address departments and to change culture, call out when things are done incorrectly, and look critically at the tactics officers use. All those things are super important to making policing better.” 

In October, the State of California altogether banned doctors, coroners, and medical examiners from attributing deaths to excited delirium,” making it the first state to do so, and restricted its use by law enforcement and in civil litigation. The Quinto-Collins family worked with Assembly member Mike Gipson to advance the bipartisan bill, providing testimony to the legislature about Angelo Quinto’s case. PHR mobilized over 2,500 people to support the bill by calling on Gov. Gavin Newsom to sign the legislation. 

Today, several states are following suit. The Colorado legislature is considering a bill that would bar police and coroners from referring to excited delirium” in lethal force cases. In the meantime, the Colorado Peace Officers Standards and Training board voted unanimously to remove excited delirium” from training materials across the state. And Illinois is also in discussions about proposing a bill to address the use of the term. 

Experts say these changes at the state-level are a crucial addition to police reform and accountability efforts nationwide.

Removing this bogus line of defense is essential to justice,” says Krupanski. We know that police misconduct and fatal use of force is concentrated among a small number of officers, and there’s evidence that shows that those officers are likely to engage in misconduct again in the future. This is an essential way to actually identify and hold those individuals accountable.”

For Angelo Quinto’s family, seeing reforms take hold creates a sense of purpose amid their sorrow — a chance to spare other families the pain they have suffered. 

If we can change the tragedy into something useful for others,” says Collins, then it gives some meaning to the loss of life that was experienced by our family.”