Updated October 9, 2026 at 6:12 AM MDT
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Tennessee hasn't yet revealed exactly what went wrong when the state failed to kill Christa Pike on Sept. 30, despite staff injecting two lethal doses into her arm. Republican Gov. Bill Lee has since paused all executions and called for an independent review of the state's lethal injection protocols, and Pike is still alive.
But Pike's attempted execution was not the only one badly mishandled under the leadership of Frank Strada, Tennessee's top prison commissioner, whose resignation was announced on Oct. 3. A similar review had already been conducted in Arizona, where three lethal injection executions were bungled while Strada was the deputy director of the Arizona Department of Corrections, Rehabilitation & Reentry.
How those executions were carried out holds clues to what may have happened behind closed doors during Pike's attempted execution.
In 2023, Democratic Gov. Katie Hobbs asked retired federal Judge David Duncan to conduct a comprehensive review of those three failed executions. Duncan spent nearly two years reviewing more than two dozen boxes of execution records, interviewing around 50 internal employees and external experts and visiting the prison where Arizona had executed people.
In an exclusive interview with NPR, Duncan explained how the prison used egregious and sometimes illegal methods under Strada's leadership in Arizona.
Records he reviewed indicated that shortly before one of the botched executions, staff members were told to search the internet about how to execute people, he said.
"There was a directive from a superior to an underling saying, 'Look up in Wikipedia to see what the appropriate dose should be,'" said Duncan.
The controlled substance used to execute prisoners in Arizona, a drug called pentobarbital, was stored in a way that could easily have led to mistakes, he said.
"It was in a locked refrigerator in a jar at the Florence prison," said Duncan, referring to the Central Unit of the Arizona State Prison Complex in Florence, where prisoners were executed in Arizona. "And the jar had no label of any kind on it. I said to the person who showed it to me, 'That could be my mother's minestrone soup.'"
Because pentobarbital is a controlled substance, federal law requires containers of it to be labeled so that it can be clearly identified. But the Mason jar allegedly holding Arizona's supply of pentobarbital didn't even describe how much of the drug was in it, Duncan said, though he estimated by looking at it that it was "mostly filled."
All major pharmaceutical companies in the U.S. refuse to provide their drugs for use in lethal injection executions, so states often turn to unconventional, and sometimes illegal, methods of obtaining them. In 2015, for example, the Food and Drug Administration confiscated execution drugs that Arizona and Texas had tried to import from India.
Some states have since turned to small compounding pharmacies to make the drugs to order for them. But some of those pharmacies that have supplied execution drugs have been reported to be plagued with problems too, including safety and cleanliness violations.
When Duncan asked to know the expiration date of the drug in the jar, he was told by a prison official that there was a document from the compounding pharmacy that made the drug that said it had no expiration date.
"And I said, 'Well, I was supposed to be able to see all of the documents. I don't remember seeing a document about that,'" Duncan said. "And she said, 'I destroyed it.'"
Three executions "cloaked in secrecy"
That lack of transparency was evident in other aspects of how executions were carried out under Strada's leadership, Duncan said, including regarding the team that inserted IVs into the prisoners and how medical staffers were paid.
In all three botched executions in Arizona, in Pike's in Tennessee and in a previously botched execution of Tony Carruthers in Tennessee on May 21, which was ultimately called off, staff repeatedly tried and failed to insert the IVs into the veins of the prisoners. And in all five of those cases, prisoners were left bloody or in pain, according to witness reports.
"She looked at the staff in the room, and she said there's one spot that was burning and hurting," said Catherine Sweeney, a reporter for WPLN News who witnessed Pike's attempted execution, describing how Pike responded when pentobarbital was first administered to her. "She was saying that she felt like her vein was going to burst."
The IV team in Arizona was not composed of doctors, Duncan confirmed. They were often current Department of Corrections employees who were not experienced in inserting IVs or independently vetted.
"They were solely selected by the Department of Corrections," Duncan said. "So you're left with people who've essentially not only had never done lethal injection before, but haven't done the most analogous thing to it."
Duncan said he was told the IV team in Arizona practiced injecting saline into a person's arm twice a year. But when he asked to view one of the team's practice sessions, he wasn't allowed, the retired judge said. He was also not allowed to interview any members of that team.
Doctors were involved in executions in Arizona to an extent, Duncan reported, and they were paid "hundreds of thousands of dollars" in cash.
"The doctor stands in a separate room that has a window, and it has closed-circuit television and a piece of plastic pipeline that runs from a panel of syringes to the inmate," Duncan said. "They paid him in cash in a brown paper bag."
Duncan questioned a lawyer for the Arizona Department of Corrections about whether the agency had prepared tax forms for employees who were paid in cash to help carry out executions. But shortly after asking that, he was fired by Governor Hobbs, Duncan said, and he never received an answer.
When asked why she fired Duncan, Hobbs previously said he had not been "up to the task."
"I'm grateful for the work he did," the governor said in 2024. "But we decided to go in a different direction."
Duncan believes he was dismissed because she didn't like the information he uncovered in Arizona, including his conclusion that lethal injection executions shouldn't be carried out because of the state's lack of transparency.
"It is so completely cloaked in secrecy that there is no opportunity for anybody who's involved in the process to share the lessons learned, to learn from mistakes or develop any expertise in best practices," Duncan said. "That made it virtually, and maybe even conclusively, impossible to effectively apply this as a method of execution."
Parts of Tennessee's execution protocol are nearly identical to Arizona's
Some of the problems Duncan found in Arizona may have been carried over to Tennessee through the states' execution protocols.
Strada was hired just one month after the Tennessee Department of Correction (TDOC) finished an investigation into the protocol that it had been using before his arrival, which called for using three drugs instead of one. A report published at the end of that review in 2022 confirmed that Tennessee had repeatedly failed to test those drugs for potency and toxins before trying to use them to execute people, although the protocol at the time required testing.
The report also showed that a pharmacy owner had voiced concern with how the three-drug plan included a weak pain reliever that could cause prisoners to suffer. "Nevertheless, TDOC chose to proceed," the report states.
When Strada was hired by Tennessee in 2023, the state switched to using just one drug — pentobarbital, the same drug that was used in Arizona when Strada oversaw the botched executions there. Tennessee also then switched to a new execution protocol. Sections of that new protocol, which was being used when Pike's execution was attempted, are nearly identical to the one used in Arizona under Strada's leadership.
TDOC said in a media advisory that it "followed every step of the State's lawful, established execution protocol approved by the Attorney General's Office" in Pike's attempted execution. A press officer at the Tennessee Department of Correction did not answer NPR's questions about how much of that protocol was copied from Arizona's or what role Strada played in the similarities, and the press officer referred NPR to Governor Lee's office.
But the bungled executions show similar patterns. Some of the sections that are most similar in the Arizona and Tennessee protocols are the sections that direct the IV team in how to execute people — and in all five mishandled executions under Strada, in Arizona and Tennessee, the IV team struggled to place IVs in the prisoners' veins.
Arizona's protocol from 2022 required that "The IV Team Leader shall ensure the catheters are properly secured and properly connected to the IV lines and out of reach of the inmate's hands." In Tennessee, the 2025 protocol says: "The Special Operations Team Leader ensures that the catheters are properly secured, properly connected to the IV lines, and out of reach of the inmate's hands."
Both protocols also state that the IV team has to consist of two or more people who could be physicians, physician assistants, nurses, emergency medical technicians, paramedics or military corpsmen. But just like in Arizona, when lawyers for the condemned asked Tennessee to provide information about the training of the people selected to be on the IV team in Tennessee, or the opportunity to interview them, officials refused.
"We don't know anything about the qualifications of the personnel," said Kit Thomas, a federal attorney who sued Strada and another Tennessee prison official last year on behalf of a group of death row prisoners. "The state has opposed our efforts."
That lawsuit alleges that lethal injection executions with pentobarbital violate the Tennessee Constitution, partly because of the state's lack of transparency. Lawyers have not been able to get any information from Tennessee about how the state obtained its pentobarbital, how it was made, how it is stored and its current quality and potency, Thomas said.
"We filed this lawsuit in March 2025, before the botched executions of Tony Carruthers and Christa Pike," said Thomas. "Before that, we were saying there was a culture of noncompliance, secrecy and recklessness. And that is even more true today than it was a year and a half ago."
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