When the Texas Rangers learned that a woman had died in a jail south of Dallas, they put Adam Russell on the case.

He found that there had been a struggle between the woman, Kelli Leanne Page, 46, who was being held on drug charges, and two guards, who entered her cell because they said she would not stop banging a hairbrush against the door.

One jailer threw her to the floor, punched her in the face while they scuffled and piled atop her as blood streamed from her nose. The other, a trainee weighing 390 pounds, pinned her down until she stopped breathing.

Six hours into his investigation, Russell indicated in his notes, he was not inclined to blame the guards for her death. And when an autopsy later determined that Page was the victim of a homicide — having died Oct. 8, 2017, of a form of asphyxiation — Russell appeared not to reconsider.

Instead, he obtained a second opinion from a retired chief medical examiner, who read the forensic report and said he believed that heart disease might have led to her death while she was being restrained. Russell later testified that the initial autopsy was a rush to judgment and that “something inside Kelli” had killed her. The guards were not charged.

For many years, Texas has made its state investigators, the fabled Rangers, available to review deaths that occur in the custody of local authorities. At least seven other states have embraced a similar approach, reasoning that outside inquiries are more likely to hold wrongdoers accountable.


But state agents do not necessarily lead to better investigations or greater accountability, according to a New York Times examination of the record in Texas. Drawing on dozens of interviews and more than 6,000 pages of investigative files, autopsy reports, police records and court filings, The Times found that state investigations can be afflicted by the same shortcuts and pro-police biases that outside interventions are meant to eliminate.

Some of the Rangers’ investigations offer a textbook example of dogged police work, like the one into the overdose death of James Dean Davis, 42, in the La Salle County jail in 2017. Ranger Randy Garcia meticulously documented the neglect of guards who mocked Davis as he screamed for help from the floor of his cell, interviewing more than a dozen witnesses and reviewing video footage and audio recordings — and securing indictments against two jailers for tampering with government records.

In other instances, the Rangers fell short of basic standards. They did not speak to all relevant witnesses, delegated investigative tasks to the agencies under review, and failed to follow up on signs that officers were negligent or behaving dangerously.

The Times identified 29 cases the Rangers investigated since 2015 in which a person stopped breathing after struggling with local authorities. None of those inquiries led prosecutors to charge anyone in law enforcement. In two-thirds of the cases, The Times found shortcuts, missteps or judgment calls that some veteran homicide detectives said might indicate a lack of effort on the Rangers’ part.

The Rangers who handled the various cases declined or did not respond to requests for interviews, and the Rangers’ parent agency, the Department of Public Safety, would not make any official available to answer questions.

It is a reality of policing in Texas and elsewhere that people sometimes die in custody, through no fault of the arresting officers. When officers do cross the line, investigators play an important role in holding them responsible. But the cases are often a lower priority than other duties because of the general reluctance among law enforcement officials to assign blame to their own.


“I guarantee you this is not a sought-after assignment for the Texas Rangers,” said Adam Bercovici, a former homicide lieutenant for the Los Angeles Police Department.

A patchwork approach

In the past decade, flashpoints of police violence across the country have focused attention not only on aggressive tactics and racial disparities in law enforcement but also on the patchwork way in which the encounters are investigated.

Some states, like California, have rarely sent their agents to review in-custody deaths, leaving those inquiries to local police and sheriff’s departments.

Washington state has recently relied on a hybrid model, dispatching teams of local and state investigators. Officers must recuse themselves if their team is investigating a home agency.

In 2014, Wisconsin became the first state to require independent investigations of deaths involving police officers.

The push to mandate independent reviews has grown since the murder of George Floyd last year by a Minneapolis police officer. At least seven states have passed measures requiring local agencies to turn over in-custody death inquiries to state officials or other outside investigators.


“Let’s face it — if you come from the same organization, you’re going to have some level of bias no matter how objective you try to be,” said Ashley Heiberger, a former police officer in Bethlehem, Pennsylvania, who advises departments on the use of force.

The 29 deaths reviewed by The Times happened throughout Texas. In at least 16 of the cases, the Rangers failed to interview everyone who witnessed the encounter. They sometimes relied on written statements or video footage instead, and in at least five investigations, they interviewed no witnesses at all.

The Times found 12 instances in which the Rangers delayed going to the scene or did not visit it. Delbert McNiel, 48, who had a history of mental illness, died in a struggle with Hamlin police officers after they restrained him and then shocked him 11 times with a stun gun in December 2017. The Ranger assigned to the case went to the hospital, photographed the body and conducted six brief interviews with the officers and paramedics involved. But his report reflected no interviews with other witnesses or a visit to the convenience store outside of which McNiel died.

Rob Bub, a 33-year veteran of the Los Angeles Police Department who now works as an investigation consultant, said a failure to examine the death location was generally a sign of “lazy investigating.”

In three cases reviewed by The Times, the Rangers assigned important tasks to employees of the agencies under investigation.

After Robert Geron Miller, 38, died following a brief stay at the Tarrant County jail in July 2019, Ranger C.H. McDonald learned that he had tussled violently with his jailers. Miller sustained head injuries when one threw him to the ground, and he complained of chest pain after another guard blasted him with pepper spray. He was dragged facedown to a cell where another jailer saw him splayed out on the floor, splashing toilet water on his face. Twelve minutes later, the Ranger noted, Miller stopped breathing.


McDonald described conducting four brief interviews in his file and left the task of watching video footage to a detective with the county sheriff’s office — the agency responsible for the jail — who reported back that he did not see any “suspicious or criminal behavior.” The Ranger closed the case about nine months later, on learning that the medical examiner had ruled that Miller’s death was caused by a sickle cell crisis.

Unanswered questions

Three cases had red flags that might have led detectives to conduct more interviews or seek additional evidence if they were not investigating law enforcement. Instead, the Rangers closed them without much scrutiny.

One involved Coy Walker, 41, who had struggled with mental illness and drug use over the years but had seemed on an upswing by spring 2015, his family would tell the Rangers. Then came the night that May when Walker showed up at his parents’ house near Weatherford, about 30 miles west of Fort Worth, in a wild panic.

Unable to calm her son down, Walker’s mother called 911. The Parker County Sheriff’s Office arrived soon after. An investigative report filed by McDonald, the same officer who handled the 2019 death of Miller in Tarrant County, documented what happened next.

The first sheriff’s deputy said she found Walker in the house, on his back and surrounded by overturned furniture and broken glass, swinging a curtain rod. She jolted him with a stun gun and was struggling to get him into handcuffs when her backup, Cpl. Ethan Stark, charged in. Stark leapt on top of Walker, put a knee on his neck and punched him in the face, according to the Ranger report. While atop Walker, the deputy “choked him with both hands” before realizing he was not breathing, according to the Ranger’s interview with Walker’s father, who witnessed the encounter. Walker was taken to a nearby hospital but could not be revived.

When McDonald interviewed the deputies, both said that Stark’s hand had slipped and accidentally grasped Walker’s throat. But an autopsy suggested more than casual contact, records and interviews show. The pathologist’s report showed that Walker’s hyoid, a delicate bone in the upper throat, was broken — an injury well known among homicide investigators as a possible sign of strangulation.


The same autopsy report showed that Walker also had a large amount of methamphetamine in his system. The cause of death was labeled “sudden death during physical restraint with neck injury and methamphetamine intoxication.” The manner was listed as “undetermined.”

Bercovici, the former Los Angeles lieutenant, and other experienced death investigators said that even if a person was found to have drugs in his system, a broken hyoid and an eyewitness account of strangulation ought to give an investigator pause. “If I was running that investigation, I would step back,” Bercovici said. “That wouldn’t pass the smell test for me.”

Records suggest that McDonald did not pause after learning of the new evidence. On the same day he received the autopsy report, he presented his investigation to a Parker County grand jury, which brought no charges.

A lack of specialists

Texas employs about 165 Rangers statewide — the Houston Police Department, by comparison, has 5,300 sworn officers — and most of the Rangers work as generalists.

“If you’re not bringing in somebody who has had a certain amount of training, you’re doing a disservice,” said Bub, the former Los Angeles detective. “There’s an expertise that goes with it.”

But training guidelines and technical best practices cannot account for every situation an investigator will encounter, and sometimes judgment calls must be made that can affect the outcome. That was the case in the death of Michael Garrett in Comal County in 2019.


As police were arresting Garrett, 18, on a drug possession charge that December, an officer suspected he had swallowed some meth. Instead of putting Garrett into an ambulance, records show, he took him to the county jail, where guards tried to strip-search him. When Garrett resisted, they forced him into a restraint device and left him outside the jail’s control room. Soon after, a guard noticed that Garrett had turned purple, and he was taken to a hospital.

Medical tests revealed meth in his system, and he was on life support when the jail contacted the district attorney’s office, which issued a sworn statement indicating that Garrett would not be charged. The jail was then able to release him from custody and bypass rules for reporting the episode as an in-custody death.

When the investigating Ranger, Joseph Evans, learned of the legal maneuver, he made no objection. He concluded that Garrett probably died because of his “intentional ingestion of methamphetamines,” and then he closed the case.