Retired Judge Says Tennessee Repeated Arizona's Execution Failures Under the Same Prison Chief
David Duncan, who reviewed three botched Arizona executions, tells NPR that unlabeled drugs in a jar and cash payments to staff were warning signs, and that Tennessee's protocol copies Arizona's.
Tennessee has not said what went wrong on Sept. 30, when staff injected Christa Pike with two lethal doses and failed to kill her. Gov. Bill Lee has since paused all executions and ordered an independent review, and Pike is alive. A retired federal judge who investigated botched executions in Arizona told NPR that the pattern looks familiar, and that it traces to the same official.
Frank Strada, Tennessee's corrections commissioner, announced his resignation on Oct. 3. Before Tennessee hired him, he was deputy director of the Arizona Department of Corrections, Rehabilitation and Reentry, where three lethal injection executions were bungled on his watch. In 2023, Democratic Gov. Katie Hobbs asked retired Judge David Duncan to review them. He spent nearly two years going through more than two dozen boxes of records, interviewing about 50 employees and experts, and visiting the prison.
In an exclusive interview with NPR, Duncan described what he found. Shortly before one execution, he said, a superior told a subordinate: "Look up in Wikipedia to see what the appropriate dose should be." The execution drug, pentobarbital, was kept in a locked refrigerator in an unlabeled jar at the Florence prison. "I said to the person who showed it to me, 'That could be my mother's minestrone soup,'" Duncan said. Federal law requires containers of controlled substances to be labeled. When he asked for the drug's expiration date, he said an official told him a document from the compounding pharmacy said there was none, and that she had destroyed it.
Duncan said the IV team was not made up of doctors and often included corrections employees without experience placing IVs. He was told the team practiced with saline twice a year, but he was not allowed to watch a practice session or interview team members. A doctor who took part in executions was paid "hundreds of thousands of dollars" in cash, Duncan said, "in a brown paper bag." He said he asked a Corrections Department lawyer whether tax forms had been prepared for the cash payments and was fired by Hobbs shortly afterward. Hobbs said in 2024 that he was not "up to the task." Duncan believes he was dismissed because of what he uncovered, including his conclusion that lethal injection should not be carried out in the state because of its secrecy.
Tennessee's problems look similar. When Strada arrived in 2023, the state switched from a three-drug protocol to pentobarbital alone and adopted a new protocol. NPR found sections of that protocol nearly identical to Arizona's, including the language directing the IV team. Arizona's 2022 protocol says the team leader must ensure catheters are "out of reach of the inmate's hands," and Tennessee's 2025 version uses almost the same wording.
In all five mishandled executions under Strada, three in Arizona and two in Tennessee, the IV team struggled to find veins. The Tennessee cases are Pike's and that of Tony Carruthers, whose execution on May 21 was called off. Prisoners were left bloody or in pain, according to witness reports. Catherine Sweeney of WPLN News, who witnessed Pike's attempt, said Pike told staff one spot was burning and hurting and that her vein felt like it would burst.
The Tennessee Department of Correction has said it followed every step of its protocol, approved by the Attorney General's Office, and did not answer NPR's questions about how much of the protocol was copied from Arizona or what role Strada played, referring NPR to Lee's office. Duncan said the secrecy leaves no room for staff to learn from mistakes or develop expertise, which he called "virtually, and maybe even conclusively, impossible" to fix.
