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Two doses of a lethal injection drug have failed to kill Christa Gail Pike, a 50-year-old woman who was due to be executed on Wednesday. Pike was taken to hospital after it was found that her heart was still beating following the procedure.

Pike would have been the first woman in more than 200 years to be put to death in Tennessee and was the only woman on the state’s death row. Her attempted execution with doses of the sedative pentobarbital went ahead despite a last-minute stay by a federal appeals court on Wednesday, which was overturned just an hour before her execution by the Supreme Court.

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Human rights experts said the botched execution illustrates why the death penalty is inhumane and should be abolished.

Clive Stafford Smith, a human rights lawyer who has represented many American death row inmates as well as detainees held at the notorious Guantanamo Bay detention centre, told Al Jazeera: “I’ve been in the execution chamber with six of my clients and it’s never the clinical process they’d have you believe. And it’s always a desperate midnight struggle to stop it.”

He added: “In the end, you have to question whether this makes the world a better, more civilised place. Why, indeed, do we kill people to prove that killing people is wrong?”

Ahead of the planned execution, Morris Tidball-Binz, the UN special rapporteur on arbitrary executions, told the UK’s Times newspaper: “If executed, Christa Pike would be a victim of torture to death. This will be a gross violation of human rights.”

Here’s what we know about what happens when an execution goes wrong.

What is the case against Pike?

Pike was found guilty of the murder of another young woman she had viewed as a romantic rival, when she was aged 18, more than 30 years ago.

In January 1995, Pike, her 17-year-old boyfriend Tadaryl Shipp and 18-year-old Shadolla Peterson lured Colleen Slemmer, 19, into a wooded area and tortured and killed her. All four were students at a Job Corps vocational centre in Knoxville.

The case attracted huge public interest, especially after it was revealed that the attackers had carved a pentagram into Slemmer’s chest, which Shipp later admitted to doing. Pike, who delivered the killing blow to the victim’s head, smashing her skull, kept a piece of Slemmer’s skull afterwards.

Pike and Shipp confessed and were convicted of first-degree murder in 1996. Pike was sentenced to death; Shipp, who was 17 at the time and therefore ineligible for the death penalty, received life with the possibility of parole.

Her case is highly unusual in that she is a woman and was a teenager when she carried out the murder. Other death row inmates who were convicted at the age of 18 – all men – have had their sentences commuted to life in prison without parole.

“Christa is a 50-year-old remorseful woman who understands her actions,” her lawyers wrote. They also argued that Pike had been the victim of appalling childhood abuse – including two rapes when she was aged 11 and 17.

Stafford Smith told Al Jazeera: “Very few women are executed, but fewer still in Tennessee – it has been 200 years. So, this is a step back to about 1820. Christa was just a teenager, and had undergone horrendous abuse as a child. Now she is 50, a totally different person. It is so pointless – will this really make the world a more civilised place?”

Slemmer’s mother, May Martinez, however, has spoken out in support of the execution.

On Wednesday, a federal court temporarily put the planned execution on hold, on legal and technical grounds. But an hour before the midnight deadline for her execution was to expire, the US Supreme Court overruled the stay on her execution, paving the way for jail authorities to proceed.

Pike had asked to be shot by an all-female firing squad instead of by lethal injection, which she said she feared would be too painful.

Her lawyers had also argued that the injection would be torturous for her as she has “small veins”. This request was denied, however.

How did the execution go wrong?

Following the Supreme Court’s order to go ahead with the execution, Pike was administered two doses of the sedative pentobarbital at the Riverbend Maximum Security Institution in Nashville, Tennessee, on Wednesday evening, according to media witnesses.

From outside the prison, The Associated Press journalist Kim Chandler reported that, initially, when the injections were administered, Pike appeared noticeably awake.

“The blinds were closed for the first time to the execution chamber at 7:46pm (23:46 GMT), they opened again at 7:49pm (23:49 GMT),” Chandler said.

“Her mouth fell open a few times, and she began to loudly snore. She gasped a few times,” she noted.

“The curtain to the execution chamber closed for the final time at 8:06pm (00:06 GMT), and she could be heard loudly snoring, clearly very alive, in the chamber until media witnesses were told to leave the area at about 8:53pm (00:53 GMT),” Chandler added.

The Tennessee Department of Correction did not immediately explain why the execution had not been completed.

According to NBC News, late on Wednesday, Pike’s lawyers had filed a federal court motion during the process seeking again to halt her execution, citing witnesses’ accounts that “executioners had injected both syringes of lethal injection chemicals and Pike is still alive and snoring”.

“Ms Pike has not lost consciousness and still has a heartbeat and is audibly snoring,” they said, according to the court documents seen by the media.

Her lawyers also told US media that while she was being treated at a hospital, she needed “immediate medical care”.

Why didn’t the execution work?

Tennessee authorities have not explained this yet.

However, Stafford Smith, who has attended several executions in support of clients in the past, told Al Jazeera that there are two probable reasons why the injection failed to kill Pike.

“The first is that the drugs were probably out of date. Something that we’ve been observing a lot for the last 10 years is that they administer drugs that are no longer valid,” he said.

Stafford Smith noted that there is, however, a valid reason for this, which is that drug companies make sedatives like pentobarbital to help people and save lives and are often opposed to their drugs being used to execute people.

“So the states have a real problem getting drugs to kill people and they’ve gone to extraordinary extents with very unreliable providers. So you can suspect that they just had an invalid batch of drugs in Pike’s case,” Smith explained.

“The other thing about Pike is that, as is very common with people who end up in her situation, they’ve been through a lot of abuse and drug abuse. So it might have been very hard to find her veins and get a needle into it. Moreover, doctors are also not allowed to take part in this process in the US. So they have incompetent people administering such drugs, which could have resulted in the injection failing,” he added.

Defending its handling of the case, the Tennessee Department of Correction said in a statement late on Wednesday that the agency had “followed every step of the state’s lawful, established execution protocol approved by the Attorney General’s Office”.

“The lethal injection chemical in the protocol has consistently been effective, and the protocol does not allow for additional procedures beyond what was carried out this evening. Christa Pike has been transported to an off-site medical facility,” the statement concluded.

What happens to Pike next?

At the moment, it is unclear, as Tennessee Governor Bill Lee has paused all remaining 2026 executions in the state following Wednesday’s incident with Pike and has called for a comprehensive, third-party review. She is currently in hospital. She may return to death row, but Stafford Smith said this is uncertain.

Has this happened before?

Yes. Botched executions do happen but the frequency varies substantially by method, according to data compiled by legal scholar Austin Sarat and the Death Penalty Information Center.

In his 2014 book, Gruesome Spectacles: Botched Executions and America’s Death Penalty, Sarat noted that from 1890 to 2010, 8,776 people were executed in the US and 276 of those executions (3.15 percent) went wrong in some way. Sarat also noted that lethal injection was the method that had the highest rate of botched executions at 7.2 percent in this period.

Previous botched lethal injection cases include the case of murderer Alva Campbell in November 2017 in Ohio. According to the Death Penalty Information Center, “the execution team first worked on both of Alva Campbell’s arms for about 30 minutes.. while he was on a gurney in the state’s death chamber and then tried to find a vein in his right leg below the knee. … About 80 minutes after the execution was scheduled to begin, the 69-year-old Campbell shook hands with two guards after it appeared the insertion was successful.”

“About two minutes later … Gary Mohr, head of the Ohio Department of Rehabilitation and Correction … called off the execution after talking with the medical team, [saying] ‘It was my decision that it was not likely that we’re going to access veins.’” But a few months later, in March, 2018, Campbell died on death row due to terminal medical conditions.

“Botched executions have happened many times. I’ve had six of my clients executed over the years. Two were with the gas chamber, two with the electric chair and two with lethal injection, and there’s almost always some form of botching,” Stafford Smith said.

“But it’s just an uncivilised process carried out by people who are pretty uncivilised,” he added.

A medicine injected just twice a year could transform the fight against HIV.

In a 2024 clinical trial involving more than 2,000 young women in South Africa and Uganda, no participants who received lenacapavir contracted HIV.

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Developed by United States pharmaceutical company Gilead Sciences, the injectable drug can be used to prevent HIV.

“It’s the most innovative tool that has reached the HIV arena for the last decade, because it’s the closest we have [to] a vaccine,” Carlota Baptista da Silva, global HIV lead at Doctors Without Borders (known by its French initials, MSF), told Al Jazeera.

The World Health Organization has recommended the long-acting injectable as an additional form of pre-exposure prophylaxis, or PrEP – medicine to reduce the risk of getting HIV.

But the arrival of the drug comes at a challenging juncture in the global fight against HIV.

International funding for HIV fell 18 percent in 2025, to $7.3bn, its lowest level in nearly two decades, according to the United Nations programme on HIV/AIDS (UNAIDS). The squeeze has already hit prevention programmes: The number of people receiving medicine to reduce risk fell from 1.4 million in 2024 to 1.1 million in 2025.

That makes the arrival of a highly effective, twice-yearly prevention option significant. The question of who can access it is now more urgent.

For MSF, the scientific question has largely been answered: lenacapavir can prevent HIV with remarkable efficacy.

The fight now is whether the rules governing manufacture, price and supply will allow that scientific breakthrough to reach the people who need it.

Why some countries are excluded

In the United States, lenacapavir costs about $28,000 per person annually. Generic versions are expected to cost about $40 a year.

A generic version is a copy of the original drug made by another manufacturer after the patent holder licenses the technology. It contains the same active ingredient, but it can be produced and sold at a much lower price.

In June 2025, the US Food and Drug Administration (FDA) approved lenacapavir for HIV prevention, giving people the option of an injection twice a year. But in several low- and middle-income countries, access to cheaper versions is not expected at scale until 2027.

Gilead is supplying its own version of lenacapavir at no profit for programmes supported by the Global Fund and the US President’s Emergency Plan for AIDS Relief (PEPFAR), with rollouts under way in countries including South Africa, Kenya, Zambia, Nigeria and Eswatini.

These are not the cheaper generic versions expected to cost about $40 per person a year. Gilead has licensed six manufacturers to produce those, with large-scale generic rollout expected in 2027.

At least 26 middle-income countries are excluded from Gilead’s generics agreement, MSF says, including countries with rising HIV infections and some that helped test the drug. Among them are Brazil, Mexico, Argentina and Peru.

“People should not really help generate the evidence for breakthrough medicine and then find that their country is excluded from affordable generic access,” da Silva said.

According to MSF, countries excluded from the licence accounted for close to 23 percent of new HIV infections globally in 2023.

Gilead has since announced a separate agreement with the Pan American Health Organization, creating an access pathway for 14 Latin American and Caribbean countries outside its generic licensing territory, including Brazil, Mexico, Argentina and Peru.

MSF argues that leaves those countries dependent on Gilead rather than able to automatically buy the cheaper generics.

MSF says it still cannot buy the drug

For more than a year, MSF says it has sought permission to purchase lenacapavir directly from Gilead for its medical programmes, without demanding a discounted price.

“Despite those requests, Gilead has not allowed MSF to purchase this medicine directly,” da Silva said.

That matters particularly in humanitarian emergencies, she argues. People displaced by conflict or disaster may struggle to take a prevention pill every day, while sexual violence and other vulnerabilities can increase the risk of HIV.

Daily PrEP pills are already available as an alternative to the injection. But unlike lenacapavir, they need to be taken consistently to provide protection. An injection offering six months of protection could be particularly valuable.

“People living through conflict [and] humanitarian crises cannot be the last in line for medical innovation,” da Silva said.

Gilead declined Al Jazeera’s request for an interview due to scheduling constraints.  In its emailed statement, it said its access strategy combines no-profit supplies, royalty-free licensing and regional agreements. It didn’t reply to questions about why it won’t sell its drug to MSF, or why certain countries were excluded from its generics agreement.

The company plans to provide enough lenacapavir for up to three million people through 2028 as generic manufacturers scale up production, with large-scale generic rollout expected in 2027.

MSF says that is nowhere near the scale required, pointing to projections that close to 20 million people worldwide need access to PrEP to substantially reduce new HIV infections. That includes all forms of PrEP, not just lenacapavir.

But countries left outside Gilead’s generic licensing deal may have another option.

Can governments bypass the patent barriers?

World Trade Organization (WTO) rules allow governments, in some cases, to bypass a drug company’s patent so cheaper versions of a medicine can be made or imported without the company’s permission.

They can also authorise government use of patents and challenge patents they consider weak or unjustified. The 2001 Doha Declaration affirmed WTO members’ right to use such safeguards to protect public health.

Brazil has used them before in the fight against HIV. In 2007, after negotiations with pharmaceutical company Merck over the price of the HIV drug efavirenz failed, Brazil issued a compulsory licence allowing it to access cheaper generic versions of the medicine.

Nearly two decades later, activists are urging Brazil to consider using those powers again for lenacapavir if patent barriers prevent affordable generic access.

MSF says governments excluded from Gilead’s licence could consider those same legal safeguards for lenacapavir, including compulsory licensing, government-use authorisations and challenges to patents.

It is also calling on Gilead to ensure its agreements with generic manufacturers do not prevent them from supplying countries where patent barriers have been removed through such measures.

For MSF, the stakes go beyond lenacapavir. The way the drug is made available could determine whether one of the greatest advances in HIV prevention in decades reaches people based on need, rather than where they live or what their health systems can afford.

“For a humanitarian medical organisation, we should not have to spend more than a year trying to find a way to buy a WHO-recommended medicine,” da Silva said.