Restrained and Sedated
Since 2020 two people have died after being forcibly sedated while restrained by Richmond police.
A Richmondside review of public records reveals inconsistencies between how the cases were investigated by the county coroner.
In this five-part series, Richmondside examines who the two people were, what happened when they died and whether systemic changes are being made to help prevent such deaths.
At first, Petronila Fernandes believed what police told her about how her brother Jose Luis Lopez ended up in a coma after they responded to a 911 call reporting an argument at his south Richmond home.
Fernandes and her husband, Filipe Fernandes, who live in San Pablo, told Richmondside that police said the 40-year-old Nicaraguan construction worker and his partner were arguing on March 17, 2020. They were told that a “confrontation” occurred and he became “medically distressed” but was able to walk to an American Medical Response (AMR) ambulance that took him to Richmond Kaiser Hospital, where he died two days later after being removed from life support.
The couple would later find that this account was very different from what can be seen in police body camera video footage, and it’s contradicted by public records obtained by Richmondside. These records show that Lopez was in an approximately 19-minute struggle at the home. Eleven police officers were present at various points, a number of them holding him facedown on the floor of his living room. They can be seen striking him with batons, handcuffing him and immobilizing him using a body wrap restraint device. They then covered his mouth and lower part of his head with a white spit mask and suggested to a paramedic that he needed to be sedated. The Fernandes couple said they didn’t know any of this until this reporter asked them about it two years after Lopez died.
Lopez isn’t the only man who has died after being restrained by Richmond police and forcibly sedated by an AMR paramedic. Ivan Gutzalenko, a 47-year-old registered nurse, died almost exactly a year later. He too was physically held down, handcuffed and given the same drug, midazolam.
Both men were reported to be in mental distress, police and witnesses said, and both had criminal histories and histories of mental health and substance abuse problems, according to family members and public documents. Gutzalenko’s family has since filed a wrongful death and federal civil rights lawsuit against the city of Richmond, police Chief Bisa French, the three officers at the scene and the emergency medical responder who injected him.
In both cases, the officers and paramedics involved were cleared of any wrongdoing. In the Gutzalenko case, the district attorney’s office said that reasonable doubt existed that the death was “caused by the administration of the sedative and/or the drugs at the hospital.”
A 2024 national Associated Press investigation into in-custody lethal restraint deaths occurring between 2012 and 2021 analyzed 94 cases of forced sedation, including the two in Richmond. Sixteen such deaths have occurred in California since 2014.
Since 2021, Richmond’s Community Police Review Commission (CPRC) has pushed to have more oversight of the Richmond Police Department, including more reviews of how certain physical restraint methods are used, among a number of other reforms, including giving citizens more time to file complaints against police and giving the CPRC the ability to automatically review these complaints.
More recently, the Aug. 4 police shooting death of 27-year-old Angel Montaño, who family members said was experiencing a mental health crisis, has some city elected officials calling for reforms in how police respond to such situations, with Richmond City Council member Claudia Jimenez saying in an email to her constituents that there is a need to “address some of the major holes in how our city responds to tragedies like this. We want to ensure that in moments of grief and trauma, families are met with care and connection.”
Richmond City Council member Sue Wilson also sent an email outlining her concerns, saying, among other things, that she plans to ask for a report about Richmond’s “non-lethal weapons policy” and to seek “resources to educate us about how we can do better in this regard.”
Contra Costa Health says it doesn’t track sedation locations or which police agencies are involved
Despite the fact that two of 16 sedation-related deaths statewide over a decade happened in Richmond, the county doesn’t keep detailed data about the practice.
Richmond police told Richmondside in April that the department does not administer the drugs and, so, does not track how often they are used to calm suspected “5150” suspects — people having a mental crisis — during police calls. The Contra Costa County Department of Health, which oversees the policies and procedures of emergency medical responders in the county, initially told Richmondside it does not track data related to the use of the sedative midazolam, commonly known by its brand name Versed. But a Public Records Act (PRA) request submitted by Richmondside showed that it does, to a limited degree.
Mental crisis hotlines
Contra Costa Health offers the following advice for anyone involved in a mental health crisis:
If you or a family member are experiencing a life-threatening emergency, call 911. If you are experiencing a behavioral health crisis, 24-hour care is available:
- A3 Crisis Response: 844-844-5544
- Access Line: 888-678-7277
- Contra Costa Crisis Center: 800-833-2900
- Text “HOPE” to 20121
According to data obtained by Richmondside, emergency medical service personnel from American Medical Response administered midazolam 4,956 times in Contra Costa County, which has a population of about 1.2 million, from 2017 to June 30, 2025. From 2017 through 2023, the last year data was available due to a change in how the numbers are tracked, 1,380 injections were categorized as “5150 pd” requests, meaning they involved situations where Contra Costa County law enforcement agencies believed the person in custody could qualify for a 72-hour involuntary psychiatric hold. That’s, roughly, an average of once every 1.9 days.
For comparison, the San Francisco Fire Department, which serves a city of about 808,000, administered midazolam more than 4,000 times from 2018 to 2022, according to a report published by the San Francisco Standard. That’s about an average of once every 2.2 days.
Richmondside filed a subsequent records request to find out where in the county those police call injections were given but was told by a county spokesperson that the county does not keep records on which local law enforcement agencies were involved. Midazolam remains in its local medication protocol and is still being administered when indicated.
Records show Lopez did not ‘walk out’ to an ambulance
Lopez’s family, who primarily speak Spanish, didn’t find out until three years after his death how seriously injured he was until this reporter, who was working for a different news outlet at the time, interviewed them. They said in interviews between 2023 and this year that they still struggle to answer many questions, including: Why did he die? How did all of this happen? And what can change so that this doesn’t happen again?
The police account of Lopez “walking out” to an ambulance was detailed in news stories about the case. In May of 2022, more than two years after Lopez’s death, Richmond Police Sgt. Aaron Pomeroy, who retired from the department in 2024, told the San Jose Mercury News that Lopez became medically distressed during the arrest but was able to walk to the ambulance.
behind-the-scenes of restrained and sedated
Richmondside’s review of public records show that is not what happened at Lopez’s home in the 200 block of South Ninth Street. Rather, Lopez spent the last conscious moments of his life on March 17, 2020 pinned down by police officers and heavily restrained.
When asked by Richmondside about the description of Lopez walking to an ambulance, current department spokesperson Lt. Donald Patchin said that he isn’t sure why or even if reporters were told that.
“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, Sgt. Pomeroy 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 went to the home after the adult daughter of Lopez’s fiancee called 911, telling the dispatcher her mother needed help. Lopez had accused her of cheating on him and reportedly ripped her clothes off to sniff them.
Kenneth Ferraro was the first Richmond police officer who entered the one-story home, which was decorated for a birthday party with a banner on a wall. (Lopez had turned 40 the day before.) They saw Lopez in a bedroom doorway and his fiancee crying nearby. As Lopez tried to step away from Ferraro, the officer lunged and tackled him, landing both men on the hallway floor, according to body cam footage.
“No! You’re gonna kill me!” Lopez yelled in both Spanish and English as other officers joined in, one holding back a loudly barking police canine at the front door. “I see the hate in you!”
Police described Lopez as unusually strong in later interviews with the district attorney’s investigator. It was later determined that he was under the influence of cocaine, according to autopsy records.
The video footage shows it took 11 officers 16 to 20 minutes to subdue Lopez, who was 5-foot-8 and weighed 230 pounds. They can be seen beating him with their fists, striking him with batons and placing him in a chokehold. They zap him with a taser (which one officer later can be heard saying “didn’t work for shit”) and physically hold him down. At one point five officers were on top of Lopez. They eventually handcuff him, put him into a body restraint called a WRAP device and place a spit mask over his face.
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.
“Can I express something that I feel?,” she said in Spanish, interrupting the officer who was interpreting the interview off camera. “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. And to mistreat someone like that because, the truth is, there were a lot of officers. And 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…”
The interviewing officer, Richmond police Det. Mauricio Canelo, and Contra Costa County District Attorney’s Office inspector Eddie Sousa, interrupted her to explain that there are levels of resisting arrest.
“To not let the police search you, that is already resisting, especially when we have a reason to be there,” Canelo said to her in Spanish. “Obviously, we were there because we were called. And screams were heard so when an officer gets there, they’re going to say ‘Oh, something is happening here.’ If they try to search someone and they become tense, that’s when the problems start.”
Richmond police Sgt. Ben Therriault, president of the Richmond Police Officers Association (RPOA), told Richmondside that officers are trained to take the information they receive from 911 dispatchers and treat it as “gospel,” using that information to gauge their response, including what level of force to use.
“One of the things people don’t understand is that when an officer is dispatched to a call they have limited information,” Therriault said. “It’s happened many times where people say things that either did happen or, even if it did happen, they were later on saying it didn’t. For us, we have to rely on that information.”
Therriault said that it would be “ridiculous” for officers to respond to a call involving a weapon or a reported act of violence on a spouse and not take it seriously.
“I have to show up with that frame of mind and if I don’t do so, I do so at my own peril and the peril of the people we are trying to protect,” he said. “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. 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.”
The body restraint officers used on Lopez is a jacket-like device that positions a person so they’re sitting at a 90-degree angle with their hands cuffed to their legs or cuffed behind their back. The legs are immobilized inside a separate cocoon-shaped covering. After putting these restraints on him, police then covered Lopez’s mouth with a fabric spit mask that encircled the lower part of his head.
Police body camera video shows that once restrained, Lopez was lying on his side on his living room floor moaning, groaning, writhing and grunting. AMR paramedic Rob Hirsch and his partner then entered the home. Richmond police Officer Michael Ricchiuto can be seen and heard saying he “needs the shot thing” while making a hand movement that appears to mimic the motion of pushing a syringe plunger. Hirsch then walked over to Lopez, knelt down and injected him in the buttocks with midazolam, a short-acting benzodiazepine that is a depressant that falls within the same class of prescription drugs such as Xanax or Ativan.
In an interview with Richmondside, Patchin reiterated that officers have no say in when medical practitioners such as paramedics decide to use sedatives during incidents.
“It is important to emphasize that the City and its Police Department have no involvement in the administration of any medication, including midazolam. Neither the City, the Richmond Police Department nor any officer ever recommends, requests, or administers midazolam — or any other medication — at any time. Instead, the decision of whether medication should be used, and if so, how and under what circumstances, is made exclusively by licensed medical professionals in accordance with the requirements imposed by the State of California,” Patchin said.
Within a minute, Lopez went silent, the video shows. At this point he remains on the floor surrounded by first responders and police.
At one point, an officer asks Hirsch if Lopez is breathing then corrects himself. Then, a minute and a half after the injection, Hirsch, his partner and several officers wrapped Lopez in a medical tarp and used it to lift him to a gurney, which was then rolled to an ambulance.
It wasn’t until paramedics loaded Lopez into the ambulance — about seven minutes after the injection — that they realized something was wrong, according to the Law Enforcement Fatal Incident (LEIFI) report. Lopez was unresponsive. They yelled for help from police and asked that the body wrap, spit mask and handcuffs be removed so they could revive Lopez.
But they could not revive him, according to records of the incident, and he was taken to the nearest emergency room, Kaiser Richmond, which was six minutes away. There, doctors worked for 10 to 15 minutes to restore his heartbeat.
According to documents from the Contra Costa County District Attorney’s Office, Lopez was listed in critical condition at the hospital, and it was determined he “possibly had no brain activity.”
Hirsch later said, reports show, that it was difficult to see if Lopez was breathing after being sedated because of the restraint device and spit mask. When this reporter contacted Hirsch for comment about the case via a social media messaging app in 2023, Hirsch replied, “I do not recall the incident that you speak of.” He was contacted again before this story was published and did not respond.
Lopez’s sister recalls moment police knocked on her door
Lopez’s sister, Petronila Fernandes, told this reporter in 2023 what happened that day in March of 2020. A Richmond police investigator and a Contra Costa County District Attorney’s office investigator knocked on the door of her San Pablo home. Richmondside filed a Public Records Act request for the transcripts of this interaction but was not given the documents by the city.
“Are you Petronila? Are you Jose Luis’ sister?” they asked.
Lopez, the couple was told, had been in a “confrontation” with police earlier that day and was in the hospital.
During the 30-minute conversation at the doorstep, the law enforcement officials asked repeatedly if the couple knew whether Lopez used drugs. His sister and her husband said they told police they had never seen him use drugs.
“Is he OK?” Lopez’s sister recalled asking, beginning to feel nervous. But, she said, they were told that Lopez was fine. He needed to rest, and the couple could see him at the hospital the next day. However, due to COVID restrictions, a visit was difficult to arrange.
“We didn’t go visit him right away because of the way things were set up at the time with COVID,” Filipe Fernandes said.
Two days later, on March 19, 2020, the family said they received shocking news via a phone call from a family member in Nicaragua. Lopez was set to be removed from life support and was expected to die later that morning.
Lopez’s fiancee and an uncle, Edgar Rene, and the Rev. Oscar Chavez of Richmond’s Aguilas Centro Familiar Cristiano, the church Lopez attended, rushed to the hospital, arriving at about 6:30 a.m. They could not square what police had told them with what they saw: Lopez lay unconscious in the ICU, his limbs unrecognizable from swelling, a machine keeping him alive.
“He was lying on a bed, hooked up to a bunch of tubes all over his body and in his nose,” Rene told this reporter in 2023. “They had covered him up with a lot of blankets, but his whole body was swollen.”
Lopez’s arms were so swollen, Rene said, that his elbows weren’t visible. His arms didn’t look like normal arms anymore.
The blood vessels in his eyes appeared ruptured. His lips were cut. So was a leg. Bruises could be seen on his chest, abdomen, knee, thigh, forearms, hand and a wrist.
By 10:45 a.m. Lopez was dead.
Publishing tomorrow: Contra Costa County coroner’s reports don’t mention that Jose Luis Lopez was sedated during the struggle with police and rule that his death was due to “excited delirium” and cocaine intoxication.
My condolences to the families and friends who have lost their loved ones.
I worked in acute Psychiatric care for 10 years. Procedures for full body restraint are statistically low frequency, even in the Psychiatric treatment setting, but not uncommon. They most often occur in the locked or high security areas and are very much less common in “open” units. The same goes for escape attempts.
Restraint and Secure procedures are conducted by no less that 5 trained personnel (1 per limb and one head) but large and very violent cases require more staff. The immediate goal is to “isolate” (control) each limb and head and get the subject off the ground where they have less leverage and individual staff can concentrate on checking a limited striking out, pushing and pulling by the subject.
The subjects’ language can be extremely bizarre, erotic, violent and jarring adding to the chaos the team is trying to get under control. This is very disturbing. The subject is then placed in “humane restraints”, padded leather cuffs on wrists and above the ankles with leather straps threaded through the restraints and secured with a keyed and locked buckle, hands generally behind the back.
The larger and more chaotically powerful subject requires more personnel. Perhaps more straps to wrap around the knees, thighs, forearms and upper arms. They may be “hog-tied”, that is wrists and ankles strapped together. Isolating the head is tricky, getting much attention to avoid spinal injury or getting bitten (or spit on in contagious conditions). The subject CAN express extreme power depending upon their physical and mental strength and a staff person may be replaced by a fresh staff (called a hand-off) to manage fatigue and maintain certain control of the situation for everyones safety and the subject is placed, face-down on the floor.
In addition, there is one licensed staff member who is responsible for drawing and injecting sedative medications generally into the right upper outer quadrant of the gluteous maximus. The subject is then transported by hand by 5 or more staff as needed, to a locked room with single bed, to which they are restrained, with observation windows. Staff are assigned to observe and record as needed.
It is a violent and disturbing event for subject and staff. Staff receive regular training on Restraint and Secure procedures, special holds for power and safety, shifting staff for fatigue (handing off), and the proper mental disposition and orientation. Teamwork is stressed highly.
Under “normal” settings the average person would not be prepared to manage their own fears and passions, to isolate their anger and confusion in service of the event. They are not familiar with the context of an individuals’ chaos or the the coordinated effort needed (though it can look confusing) to execute such a maneuver safely.
Further, observers unfamiliar to a restraining procedure may not be prepared to handle their own internal responses either. I’ve seen the effect of viewing this by family members and their reaction is understandably upset. To see ones’ child, spouse, friend handled in such a manner is disturbing. Yet what may be even more disturbing, and the article doesn’t touch on this, is to see someone you care about absolutely lose control. (Actually very few people understand what that even means or looks like). It may be the first time they have seen this, or remind them of a similar past event best forgotten, that a concerned person has actually see their loved one “come totally apart” and attempt to injure people right in front of them. It is jarring. Fear, embarressment, bewilderment, desperation, it is a long and confusing list.
After such a Restraint and Secure procedure the staff meets for a debrief, to check in with each other for mutual support, maybe for tears or rage/fear or bewilderment. The whole thing is not taken lightly, even by the most experienced staff. Consequent scrapes, bruises, torn clothing, and sore muscles are common in such adrenalin-charged events. Curiously, all of these things are a metaphor for the consequent psychic disturbance felt by both subjects and staff. This has a lasting effect and is no little thing.
But this all take place is a pretty quiet and controlled setting where programs and procedures are in place. In a treatment setting the subject has “signed in” for treatment or held involuntarily for their own safety or the safety of others. So there is a sense, of “in for a penny, in for a pound” commitment. Loved ones may have established relationships with staff, understanding their care and devotion, which can carry family member through this. The debriefing that staff experiences can extend to concerned friends and family as the need is seen.
The Police, arriving on “the scene” do not have these advantages. Both the subject and concerned loved ones are more familiar with the event. The Police can be seen as rescuers or intruders, fully armed and kevlared, not nice folks in blue coats. They can be seen as a regrettable necessity, sometimes the caller has feeling of regret, wishing they hadn’t called the police, especially after the event.
For their part, the Police arrive to a strange and uncontrollable space. They themselves come from a crime management headspace which, in fairness, is evolving as the subtleties of community engagement are revealed and procedures put in place. Over the years the Police have become more adept at managing such situations. However, when they go bad, when the subject cannot cooperate, refuse to cooperate, threaten people, become wild and uncontrollable, and challenge every restraint modality, it is up to the Police to be in control. Is there time to call a social workers of a trained Psychiatric person? No. Can you just back away and let the subject cause damage? No. Should they risk their lives? No.
The tone of the article is pretty fair but it still leaves one with the sensational impression that the subject is a victim and the police are the perpetrators. I believe that the public is more inclined to think that way as well. Consider a patient that dies in a hospital. Short of malpractice, few make the patient a victim and the Physician a perpetrator. The Police are easy and popular targets.
So much simply cannot be anticipated and bad things, even deaths, happen. Of course, that is no consolation. Again, my profound sympathies to the families and friends who have suffered this loss. Further, I express my heartfelt sympathies for the Police who have had to manage these issues.
I feel that while the actions in the moment can be seen as black or white, the fact that statements by these officials are so incorrect.
My heartfelt sympathies to the police as well, but why did they have to lie to family? A coverup is still a coverup.