Salt Lake City police officers didn’t stray from their training when they restrained an erratic and seemingly confused woman on a cold January morning three years ago — but she still lost consciousness during the arrest and ensuing struggle and died weeks later in the hospital.
That is an issue, said Salt Lake County District Attorney Sim Gill on Tuesday, calling for the agency to revisit its officer training to avoid contributing to deaths like these in the future.
An autopsy found 40-year-old Megan Mohn died from cardiac arrest, likely due to the combination of methamphetamine intoxication and being physically restrained. Attorneys representing her estate had already filed a lawsuit in December 2023 against the agency claiming just that, and like Gill, their complaint argued officers needed to be properly trained.
But Gill on Tuesday stopped short of charging the officers, saying that while the autopsy found that their actions likely contributed to Mohn’s death that morning, an expert in police use-of-force said that the officers also comported with their training and acted reasonably.
Gill wrote in a letter explaining his findings to Salt Lake City police Chief Mike Brown that “[i]t would be unethical at this stage to prosecute officers who act consistent with their training when that training may be inconsistent with the medical realities of physically compromised individuals who they must confront daily.”
Brown, in a written statement, affirmed that “officers acted in accordance with their training” when they detained Mohn and “applied reasonable force to control the situation while addressing Ms. Mohn’s continued resistance and the immediate threat to officer safety.”
“The death of Megan Mohn,” Brown said, “is a tragic case that underscores the challenges officers face almost every day when interacting with people whose actions and behaviors are influenced by the illegal use of controlled substances.”
The agency has not updated its training standards in response to Mohn’s death, police said, but now that Gill’s office has completed its review, the Police Department can begin its internal evaluation. A civilian review board will also look into the case.
From there, the agency will “determine whether any training adjustments are necessary.”
The city denied all of the lawsuit’s allegations in a response filed last November, saying repeatedly that the officers’ body camera videos “speak for themselves.”
Gill said he relied on video of the arrest, as well as autopsy results and a consultation with a police use-of-force expert to come to his conclusion. All of the involved officers — Joshua Hoyle, Sherwin Mansourbeigi, Dalton Hatch, and Todd Goodsell — declined to speak with investigators about what happened, asserting their Fifth Amendment right against self-incrimination.
‘They’re going to kill me’
(Bethany Baker | The Salt Lake Tribune) Kseniya Kniazeva holds a photo of her friend Megan Mohn, an unsheltered woman who became unresponsive during her January 2022 arrest, on Wednesday, March 22, 2023 in Salt Lake City, Utah.
Off-duty Salt Lake City officer Hoyle initially found Mohn on Jan. 11, 2022, at about 3:30 a.m.
Hoyle had been working part-time security at a nearby Marathon Petroleum refinery, close to 900 North 400 West, when he saw Mohn carrying two pieces of rebar and yelling, according to Gill’s letter.
Mohn dropped the rebar when Hoyle asked but wouldn’t give him her name. Around 3:35 a.m., Hoyle handcuffed her and helped her sit on a patch of grass.
Another officer — Mansourbeigi — arrived about a minute later as Mohn yelled for help. Body camera video shows Mohn breathing heavily and looking around wide-eyed. She asked the officers, “Will one of your use your cellphone to call the police?”
An officer tells her, “We are the police.”
“Yeah,” she responds, “but I want to hear them confirm that.”
Then, she can be heard yelling for help again, shouting, “They’re going to kill me,” as she stands up. Officers pull her back to the ground and continue to ask for her name or ID, which she said had been stolen.
She again pleads, “I don’t want to die. Please. I have so much stuff to do.” Mohn later says she’s “really scared” and “f----- up.”
(Bethany Baker | The Salt Lake Tribune) A display board shows photos of Megan Mohn, a woman who became unconscious during an arrest and later died, during the “Dance for Justice - Remembering Megan Mohn” event on the steps of the Utah State Capitol on Sept. 11, 2022.
Just before 3:40 a.m., officers tell Mohn that they are going to cut her backpack off if she doesn’t give them her name. Mohn again screams for help, telling officers to stop and that it’s a “good backpack.”
She then begins to kick at officers and fight for the bag. The officers respond by forcing her onto her stomach and side and holding her down with a knee on her back and hands on her legs, Gill’s letter noted.
In the ensuing three minutes, another officer — Hatch — arrives, using his knee to hold Mohn down from the other side. Mohn continues to shout for help, but her screams and jerks becoming increasingly infrequent until she moves for the last time at 3:43 a.m., Gill said.
About a minute later, officers note Mohn is no longer responding and turn her to a “recovery position” on her side. Police then called for medics to respond.
By 3:44 a.m., officers can no longer see Mohn’s breath (it was below freezing that morning) and they remove her restraints. At this point, police said she had a pulse.
Medics arrived by 3:51 a.m., and a minute later, officers determined Mohn’s pulse was gone and began chest compressions. Mohn’s pulse returned at 4:04 a.m., and medics intubated her and took her via ambulance to a nearby hospital.
She remained in the hospital for 19 days before dying. Gill wrote that she never regained consciousness.
Better training needed, D.A. says
(Chris Samuels | The Salt Lake Tribune) Salt Lake County District Attorney Sim Gill presents findings from separate police shootings while at the district attorney’s office in Salt Lake City, Thursday, May 23, 2024.
Gill consulted with Eric Daigle, an attorney and law enforcement expert, to make his decision. After reviewing the evidence, Daigle wrote in his own letter that the officers’ actions were “reasonable or necessary,” given that Mohn was resisting and kicking at them, and they were “consistent with the general industry standards for a law enforcement officer using force.”
He added that Salt Lake City police provide annual use-of-force training to its officers and that all involved officers had received training on de-escalation, arrest control techniques and mental health and crisis interventions within six months of Mohn’s arrest.
On Tuesday, Gill brought in two additional experts to speak to the case: Amanda O’Driscoll, an independent medical consultant, and West Jordan police Chief Ken Wallentine.
Mohn appeared to be in a state of “excited delirium” when she was arrested, O’Driscoll said. In this state, a person is acting erratically — “running around and cannot be reasoned with” — and they don’t respond to de-escalation techniques.
That’s because, O’Driscoll said, the person’s brain is flooded with neurotransmitters, like adrenaline and dopamine, causing extremely high blood pressure and body temperature, as well as fast heart and breathing rates.
She compared it to “a vehicle engine being over-revved and red-lined, and the gas pedal is never released.”
“If they are not treated, the engine will blow,” she said, “resulting in the patient’s death.”
Many such cases, like Mohn’s, involve the use of stimulant drugs, and O’Driscoll said that even past drug use can damage cardiac muscle, making it easier for someone to succumb to cardiac arrest.
O’Driscoll said that these kind of cases are challenging for officers and other first responders, who struggle to balance safety needs with providing medical care. But, she said, it’s important for officers to recognize these signs and allow a person to breathe through such episodes.
Many officers, O’Driscoll said, are taught that if a person is yelling, that means they can breathe. But in a state of excited delirium, the patient isn’t suffering from a lack of oxygen, but a build up of carbon dioxide, which they body is trying to release.
“It is vital that during a law enforcement encounter, the patient must be allowed to breathe heavily and deeply,” she said. “Excess stimulation that isn’t absolutely necessary to keep everyone involved safe should be avoided, if possible.”
Wallentine, who is on the board of directors for the Institute for the Prevention of In-Custody Death, said “effective police departments are learning organizations.”
“They require their officers to be learning officers,” he continued, “training officers to recognize the signs of medical events so that we can better intervene, and earlier intervene, to prevent arrest-related deaths.”
He encouraged officers to be on the lookout for signs of medical distress — including the signs of excited delirium — and call medics to the scene as soon as possible.
Gill said his office, in conjunction with the Office of the Medical Examiner, would pay for O’Driscoll to provide training for local law enforcement agencies to update their practices to better align with medical science. He noted Mohn’s is the eighth in-custody death his office has reviewed since 2019.
Joshua Ostler, an attorney litigating the lawsuit on behalf of Mohn’s estate, said Tuesday that Gill’s findings “corroborate the allegations in the lawsuit.”
“It remains undisputed that several officers placed Ms. Mohn in a hog-tie position, knowing that she had a diminished capacity and was in a state of excited delirium,” he said. “This has been a violation of clearly-established law for several decades in this jurisdiction and others around the country.”
He added that Salt Lake City police’s “training, practices, and policies are not up to date and that the individual officers' actions in this case were contrary to the weight of medical literature and expert opinion.”
The lawsuit had stalled in court, awaiting Gill’s decision. Ostler said the case will now move forward and that the legal team looks forward to “bringing some measure of peace and justice to [Mohn’s] loved ones.”
