California coroner didn't hold inquest in death of man who was sedated while restrained by police

But despite the similarities, a Richmondside in-depth review of these cases uncovered some key differences in how they were investigated by the Contra Costa County coroner, who has declined multiple requests for interviews.

In the case of Jose Luis Lopez, a 40-year-old construction worker from Nicaragua who died after a violent struggle with nearly a dozen officers in his Richmond home in March of 2020, there was no mention by the coroner that Lopez had been forcibly sedated with midazolam by an American Medical Response paramedic.

The coroner’s office also bucked protocol by not invoking an inquest in his case, a standard process for in-custody deaths where an independent citizens’ panel reviews cases. However, in the case of Ivan Gutzalenko, a 47-year-old nurse from Concord who died in March of 2021 after collapsing on a Richmond street during an unknown mental and/or physical crisis, the coroner’s report did mention that an AMR paramedic sedated him with the same drug. The office also followed protocol by holding an inquest.

A 2024 Associated Press investigation into in-custody deaths examined 94 cases nationally involving forced sedation between 2012 and 2021. In addition to the two in Richmond, the other San Francisco Bay Area cases included one in Oakland, three in San Francisco, two in Los Angeles and one in Pleasanton.

All told, 16 deaths after forced sedations during police incidents have occurred in California since 2014.

In Richmond, the families were told little by investigators about how their loved ones died.

Lopez’s sister, Petronila Fernandes of San Pablo, said that police told her Lopez was in a “confrontation” and became “medically distressed” but was able to walk to an AMR ambulance that took him to the Richmond Kaiser Hospital, where he died after being removed from life support two days later. This echoed what Richmond police also told local media in the two years following Lopez’s death.

But a review of public records and police body camera video footage paints a much different picture of what happened when police went to Lopez’s home on March 17, 2020 in response to a 911 call reporting possible domestic violence.

“No! You’re gonna kill me!” Lopez yelled in both Spanish and English as the police officers threw him to the floor and held him down while another officer stood with a loudly barking police canine at the front door. “I see the hate in you!”

Lopez struggled for 19 minutes with up to 11 officers present. He was tased, hit with batons, physically held down, handcuffed and eventually immobilized in a body WRAP device and a spit mask.

Police body camera video shows that once restrained, Lopez was lying on his side on his living room floor moaning, groaning, writhing and grunting. As AMR paramedic Rob Hirsch and his partner enter the home Richmond police Officer Michael Ricchiuto can be seen and heard saying Lopez “needs the shot thing,” while moving his hand, apparently mimicking the motion of pushing a syringe plunger.

Hirsch then walked over to Lopez, knelt down and injected him in the buttocks with midazolam (which is known by its brand name Versed), a short-acting benzodiazepine that is a depressant that falls within the same class of prescription drugs such as Xanax or Ativan.

A key point of contention in the Gutzalenko lawsuit is the role of paramedics in sedating police suspects. A judge, in a March 2025 ruling squashing the defense’s motion to dismiss the lawsuit, questioned whether paramedics giving such injections are acting on behalf of the state.

U.S. District Court Judge Edward Chen wrote that factual questions remain about whether the paramedic who injected Gutzalenko acted under “color of law,” referring to the appearance of legal authority that may not exist. Gutzalenko was handcuffed and being held down on the sidewalk by two Richmond police officers when he was injected.

“The fact that the decedent was not resisting or thrashing at the time Mr. (Damon) Richardson (the paramedic) injected the decedent with Versed begs the question, ‘What medical purpose was being fulfilled by the injection,’ ” Chen wrote. “Might a law enforcement function (instead of medical care) be implied?”

In Lopez’s case, he was so heavily restrained when he was injected he could not move.

Richmond police spokesperson Lt. Donald Patchin stressed that officers have no say in when medical practitioners such as paramedics decide to use sedatives during police incidents.

“It is important to emphasize that the City and its Police Department have no involvement in the administration of any medication, including midazolam," Patchin said in a written statement. “Neither the City, the Richmond Police Department nor any officer ever recommends, requests, or administers midazolam — or any other medication — at any time.”

Jerry Threet, a lawyer and the former investigator for Richmond’s citizen police commission, which reviews complaints against the department and its officers, disagrees with what Patchin said. He said officers ultimately can influence paramedics’ decisions by what they say or don’t say.

“So in effect the officers are going to control whether they (the person) get a sedative, or not, by how they describe a suspect,” Threet said.

After Lopez was sedated, he fell silent and was wrapped in a full-body medical tarp, placed onto a gurney and wheeled out of the house to an ambulance, which is when it’s noticed that he’s not breathing.

Patchin said in a recent interview that he isn’t sure why or even if Bay Area reporters were told that he walked out.

“I don’t know if that was said. If it was said then it is a misstatement because he did not walk out on his own accord,” Patchin said. “Unfortunately, (that sergeant) is no longer with the department. I can’t speak on what he said but I can say that in reviewing the body cam footage he did not walk out.”

Police described Lopez, who was 5-foot-8 and weighed 230 pounds, as unusually strong in later interviews with the Contra Costa County district attorney’s investigator. It was later determined that he was under the influence of cocaine, according to autopsy records.

His fiancee would later tell police and district attorney investigators that he had not physically hurt her and that she could not understand why the officers had used so much force.

“I feel that he did wrong in resisting but I don’t think the authorities did the right thing because they are supposed to give a good example. … I know that he resisted, because he was under the influence, but for them to grab him like that, hit him with batons and kick him when he didn’t do anything …”

Richmond police Sgt. Ben Therriault, president of the Richmond police union, said officers responding to calls involving a weapon or a reported act of domestic have to take them seriously. He said officers rely on the information they receive from 911 dispatchers to gauge their response, including what level of force to use.

“If we don’t act then it’s like, ‘Why didn’t you act? You were told this, this is what they said.’ That’s one of the biggest pieces of just understanding law enforcement,” he said. “You have to prepare yourself under the auspices of, ‘This stuff is gospel,’ what you’re hearing and what you’re being told. The sooner you can garner and learn more information, the better.”

Lopez was taken to a hospital six minutes away. There, emergency room doctors restored his heartbeat, but he remained comatose, never to awake again.

AMR paramedic Hirsch would later tell investigators it was difficult to see if Lopez was breathing after he was sedated because of the restraint device and spit mask. When he was contacted for comment by this reporter in 2023, he replied, “I do not recall the incident that you speak of.” He was contacted again before this story was published and did not respond.

When Lopez’s family visited him in the Kaiser ICU, they could not square what they saw with what police had initially told them — that he was fine and “needed to rest.”

They said he was unrecognizable — swollen, cut and covered in bruises.

On March 19, 2020, Lopez was removed from life support and declared dead, just three days after his 40th birthday.

Eventually the county coroner pathologist, Dr. Ikechi Ogan, determined that although Lopez was severely injured, the injuries did not cause his death. The cause of death, the autopsy report said, was “accident/drugs,” specifically “acute cocaine toxicity (excited delirium) due to substance abuse.” The report also noted other “significant conditions” were present: “Evolving Acute Pneumonia,” “Acute Urinary Tract Infection,” “Subphrenic Abscesses” (infected fluid in the body that can result from trauma or surgery) and “Soft Tissue Injuries.”

Just two months later, George Floyd would die at the hands of Minneapolis police, and the controversial “excited delirium” diagnosis would eventually be debunked by leading medical organizations and abandoned by many law enforcement agencies, including the Richmond Police Department.

Today Richmond’s police policy manual says that excited delirium remains a “subject of debate ” among medical professionals and is not a universally recognized condition. Officers are instructed to not describe someone’s “demeanor, conduct, or physical and mental condition as ‘excited delirium.’ “

“It (excited delirium) became very politically fraught as you can imagine because there were instances where people would just use that term to justify various ways of treating a patient,” said Dr. Senai Kidane, director of Contra Costa County Health’s Emergency Medical Services, which oversees the county’s paramedic contracts.

The county changed its reference from “excited delirium” to “severe agitation” in late 2021 and early 2022, he said.

Five years later, Lopez’s sister still searches for answers.

“If I don’t fight for him then who will?” she said, battling tears. “If there’s inappropriate actions by police then that needs to change so that these practices don’t continue. That’s my point of view. But it’s been years now and the system continues to operate.”

Gutzalenko, who died in March of 2021 about 10 months after Floyd’s death in Minnesota, was a father of two and had worked as a burn unit nurse. He struggled for years with mental health and alcohol abuse issues, his estranged wife and family members said.

On the day he died witnesses called 911 to report that a man was acting erratically, walking into several Richmond businesses and stealing an energy drink from a liquor store.

When police arrived, he collapsed on a sidewalk, telling an officer he couldn’t breathe, according to police body camera videos. He was initially cooperative, thanking the police officer who promised to help him, but he became upset when another officer suggested putting him on a “5150” psychiatric hold. That officer also threatened to shock him with a stun gun.

After an AMR paramedic injected him with midazolam, he soon stopped breathing and was pronounced dead within about 90 minutes, a review of public records showed. Contra Costa County investigating authorities would later rule his death was accidental, due to “prone restraint asphyxia and cardiac arrest while under the influence of methamphetamine.”

His family’s lawsuit alleges that AMR failed to properly train the paramedic, Richardson, who had told investigators he failed to “aspirate” the syringe — a critical safety step to avoid accidental intravenous administration of the sedative. It also accused the company of not having midazolam protocols and of not having a physician-approved policy for chemical restraints. The company, it said, instead had only an unsigned, unapproved outline for midazolam administration, not a formal physician-approved protocol. (It’s unknown whether AMR has changed its protocols. AMR declined to comment for this article, citing patient confidentiality rules.)

Contra Costa County District Attorney Diana Becton, who is facing a recall effort that accuses her of being soft on crime, found that reasonable doubt existed that Gutzalenko’s death was “caused by the administration of the sedative and/or the drugs at the hospital.”

His estranged wife, Honey Gutzalenko, remembers him as a devoted, loving father who had a drinking problem. But as a young man, she said, he wanted to become a Greek orthodox minister. When that didn’t pan out he became a nurse.

“He figured the next best thing to do God’s work was to be a registered nurse,” Gutzalenko said. “He was an outstanding nurse who worked in critical care in the neighborhood where he lost his life.”

She said his death devastated the family and his children.

“It’s unimaginable. This entire thing I would have never, ever imagined would happen and it’s a shock every time I think about it, every hour of the day still, the time doesn’t help. It doesn’t get better like they say it does,” she said.

This story was originally published by Richmondside and distributed through a partnership with The Associated Press.