Their deaths were similar. The Contra Costa coroner’s process was not

Although emergency room doctors restored Jose Luis Lopez’s heartbeat after he was forcibly sedated by a paramedic while heavily restrained by Richmond police officers, he never woke up again.

After Lopez was put on life support on March 17, 2020, records show that, in anticipating his possible death, Contra Costa County that evening launched an investigation under its Law Enforcement Involved Fatal Incident (LEIFI) protocol, which requires a review of every law enforcement-related death.

The LEIFI protocol requires that the district attorney’s office determine whether any individual involved in a death should be held criminally liable. Generally, the focus is on the actions of law enforcement officers.

The use of force applied during the 40-year-old electrical worker’s arrest during a reported domestic violence incident with his fiancée was documented in four separate reports: by the coroner, the LEIFI, the Richmond Police Department’s Office of Professional Accountability (OPA), and Richmond’s Community Police Review Commission independent investigator.

Diana Becton, Contra Costa County’s district attorney, ultimately determined in 2022 that “under the totality of the circumstances the officers’ use of force was reasonable” and none of them could be held criminally responsible. Becton’s report did not discuss whether the use of midazolam by American Medical Response paramedic Rob Hirsch was appropriate, but did note, in the summary of the incident, that the drug had been administered. Hirsch was never charged with a crime and remains employed by AMR, according to his LinkedIn profile. This reporter contacted him in 2023 for comment, and he said he didn’t recall the case.

The LEIFI protocol also calls for the coroner’s office to open a public inquest — a public hearing overseen by the Contra Costa County Sheriff-Coroner’s Office in which a randomly selected jury of citizens reviews specific cases, such as in-custody deaths. Such inquests are seen as a “valuable mechanism for informing the public, decedents’ families, the news media and other interested parties of the facts of LEIFI cases” and “also provide another opportunity to develop further information about such incidents,” according to the protocol. In Lopez’s case, no public inquest was held.

Coroner didn’t respond to Richmondside’s questions about why an inquest wasn’t held in Lopez case

At times, according to the most recent LEIFI agreement, published in 2023 by the Contra Costa County Police Chiefs Association, in a “limited number of cases,” an inquest may not be necessary, but all involved law enforcement agencies must be in agreement.

It states that, “… where the facts of a LEIFI incident are very clear and law enforcement’s role was obviously appropriate, inquests may not be necessary. In other cases, the filing of criminal charges against someone in connection with the Protocol incident may provide an adequate opportunity for public access to the facts of the Incident. In either case, the Sheriff/Coroner, and the Police Chief(s) of all involved LEAs, and the District Attorney would have to all agree that an Inquest is not needed.”

The coroner’s office, which reports to Contra Costa County Sheriff David Livingston, did not respond to multiple requests from this reporter between 2023 and now asking for comment on why an inquest wasn’t held. In fact, the absence of an inquest is being called a “cover up” in an ongoing federal lawsuit about the death of Ivan Gutzalenko, a Concord man who died a year after Lopez after being given the same drug while also being restrained by Richmond police during his arrest. (You can read Richmondside’s stories about the Gutzalenko case later this week.)

In Gutzalenko’s case, however, an inquest was held, with the citizens jury affirming the coroner’s determination that the cause of death was an “accident.”

In an email referenced by the San Jose Mercury News, which wrote a story about the LEIFI inquest protocol not being followed in Lopez’s case, a DA inspector emailed the sheriff’s office about the inquest status on Jan. 26, 2022. On Feb. 7, 2022 a sheriff’s deputy with the coroner’s office responded that there would be no inquest and that “the manner and cause of death has been completed and the death certificate has been filed with the state.” The fact that a district attorney’s official was unaware that the coroner’s office had decided against an inquest would appear to contradict LEIFI protocol stating that all involved agencies need to agree on the decision one way or the other.

In an interview with Richmondside, Richmond police Lt. Donald Patchin, the department’s spokesperson, said the police department invoked the LEIFI protocol for Lopez’s death, which would automatically include a coroner’s inquest, but that the police department typically doesn’t specifically request that an inquest be done or not.

“The whole purpose of this LEIFI is that you have independent entities operating autonomously without influence from each other conducting their own scope of the investigation,” Patchin said. “As far as the inquest being done, we have no say in that.”

Patchin said that the coroner’s office ultimately determines if an inquest is held. He said given that Lopez died at the start of the Bay Area’s mandated COVID shutdowns, it might have been possible that inquest protocol, in which a panel of randomly selected jurors is convened, wasn’t followed. He also said that those who made that decision in Lopez’s case are no longer working for those respective agencies.

“My understanding is that there are no notes and no way to determine now why the inquest didn’t happen,” he said. “I have no indication at all that we didn’t request one and I don’t know of any case where we either request or don’t request one. By the activation of the protocol it would be normal that one would be done.”

The county coroner’s forensic pathologist, Dr. Ikechi Ogan, determined that although Lopez was severely injured during his arrest, 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.”

However, a review of public records by this reporter found that the coroner’s autopsy incident report and the toxicology report were missing information: namely the fact that a paramedic injected Lopez with the sedative midazolam about seven minutes before first responders noticed he wasn’t breathing.

The coroner’s office did not respond to multiple inquiries from Richmondside about why this information wasn’t included.

In a final note at the end of the report, the coroner noted, in all caps: “DECEDENT BECAME UNRESPONSIVE WHILE HE WAS INVOLVED IN A STRUGGLE WITH POLICE. PER HISTORY, THERE WAS NO AIRWAY OCCLUSION OR MECHANICAL OBSTRUCTION OF RESPIRATION, ALTHOUGH POLICE ADMIT PILING ON THE DECEDENT.”

Typically, autopsies include toxicology reports that reveal what, if any, types of illicit drugs, pharmaceuticals or other toxic substances were in a deceased person’s body at the time of their death. In the case of Gutazlenko, a 47-year-old nurse from Concord who stopped breathing minutes after being sedated by a paramedic on a Richmond street while being held down and handcuffed by police, the coroner’s report did mention that he had been sedated with midazolam, though it did not attribute the drug with contributing to his death. 

Contra Costa paramedics injected midazolam in 1,380 ‘5150’ police calls between 2017 and 2023

Midazolam is regularly administered in hospitals to help patients relax before medical procedures. Paramedics sometimes inject the drug to calm combative or agitated people before taking them to a hospital. But, because the drug can slow breathing and cause death, a patient’s vital signs must be closely monitored, according to medical experts.

According to data obtained by Richmondside, emergency medical service personnel from the company American Medical Response gave the drug 4,956 times in Contra Costa County, which has a population of about 1.2 million, from 2017 to June 30, 2025. Of those calls, between 2017 and 2023, the last year for which the 5150 injection data is available, 1,380 injections were given. The “5150” classification means 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.

The drug is a “short-acting benzodiazepine,” according to Dr. Carter Lebares, a UC San Francisco associate professor of surgery interviewed by this reporter in 2023. In lay terms, she said, it is a depressant that falls within the same class of prescription drugs such as Xanax or Ativan.

A standard use for midazolam, she said, is to treat someone who is agitated and, when injected intramuscularly — as it was with Lopez — the dosage is generally 2.5 to 5 milligrams. Then a person can be reevaluated to see if more medication is needed.

If the patient is intoxicated, Carter said, it is crucial to continually evaluate how they are responding to the drug.

“This can include when people are intoxicated on cocaine or meth. Any type of those super-activating drugs,” she said. “When people are intoxicated like this the effect (of a sedative) can be delayed.”

Physiologically, Carter said, police restraint devices alone do not affect how such drugs are metabolized, although restraining a patient’s movement can have other effects. Lopez’s legs and arms had been fully immobilized in a wrap device, which handcuffs the arms to the legs, and a spit mask that wrapped around his head and mouth.

“When people are constrained, there are more things going on than the physical constriction on their rib cage,” she said. “Most living things have anxiety when they are constrained. It makes you breathe faster and more shallowly and then you can’t get as much oxygenation. Plus, you are physically wrapped up so all of those things can compound on each other.”

In Lopez’s case, paramedic Hirsch told police and district attorney investigators in a 20-minute interview that he injected Lopez with 5 milligrams of midazolam, as is standard in cases of agitation and in compliance with AMR protocol, a protocol that is overseen the Contra Costa County Health Department, according to an audio recording of the interview district attorney investigators had with Hirsch the night Lopez was injected.

In Contra Costa County, all AMR paramedics are trained to follow the county’s adult behavioral protocols for the administration of midazolam, an AMR spokesperson told this reporter in 2023.

At that time, according to the protocol, paramedics were required to assess the patient’s level of agitation as “mild, moderate, severe or excited delirium,” according to the Contra Costa County Department of Emergency Medical Services’ treatment guideline.

In that guideline, depending on the initial assessment, paramedics responding to incidents that were deemed “severe or excited delirium” were told to reassess patients prior to administering a sedative and to give 5 milligrams intramuscularly or 1 to 3 milligrams intravenously in severe cases; excited delirium cases call for 10 milligrams to be given intramuscularly. Paramedics were advised to evaluate other restraints being used on the patient and to “monitor and reassess.”

New policies call for paramedics to ‘continuously monitor’ sedated patients

According to Dr. Senai Kidane, director of Contra Costa County Health’s Emergency Medical Services, those changes were made in late 2021 and early 2022 in the aftermath of George Floyd’s murder and the national attention and scrutiny “surrounding how patients were treated by the law enforcement and EMS community.”

“The professional society that guides our industry, the National Association of EMS Physicians (NAEMSP), came out with a position statement that provided guidance nationally as to how these protocols should be administered and in guidelines that informed the practice of treating these patients,” Kidane said. “The primary changes that were made to that protocol about three years ago, the (NAEMSP) position paper, recommended that there needed to be more objective criteria for the various levels of agitation and the appropriate response.”

Those changes, he said, have come in the form of stratifying the levels of agitation while giving direction as to how paramedics should respond to the varying degrees and spectrum of agitation they might encounter.

Kidane said that, typically, midazolam, which he described as a universally used sedative, is administered by paramedics in the field to calm a confused or agitated patient and can be medically necessary for the patient’s health.

“It’s not just to subdue the patient to prevent physical injury but there’s a medical consequence for not treating these patients,” he said.

Kidane said underlying medical issues — such as low blood sugar or metabolic derangements — can cause confusion and agitation if not addressed properly.

“The other issue is the agitation itself, if prolonged, can lead to a metabolic crisis,” he said. “So somebody particularly who is impervious to fatigue from a protracted physical struggle can release a host of toxic enzymes from their muscles, dangerous electrolytes, lactic acid into their bloodstream which can cause serious arrhythmia to irritate the heart.”

Since then, the treatment guidelines have changed. Currently, the 2025 treatment guide has eliminated all references to “excited delirium” and changed it to “Severe with Altered mental status (AMS).”  The new classification calls for medical personnel to monitor and reassess prior to administering a 10 milligram maximum dosage of midazolam, and specifically calls for monitoring a person’s breathing. 

According to Richmondside’s review of police body camera video footage, after Lopez was sedated he was left lying on the floor in the restraints while ambulance crew members and police stood nearby. No medical monitoring can be seen taking place. 

Currently, Kidane said that paramedics who administer midazolam are now told to make sure they can continuously and clearly see that a patient is breathing effectively and to use the least physically invasive restraint methods. It’s also advised that a sedated patient be positioned on their back, not face down or lying sideways, as Lopez was.

“We have directions for all of this,” Kidane said of the new guidelines that were released in late 2021. “So anything that further compromises that ability, including patient positioning, the restraint methods used, is discouraged and, not only that, (paramedics) are supposed to be able to continuously monitor the patient and their breathing status and cardiac status after implementation or use of any of these methods. It’s imperative.”

Although midazolam has been used for decades, Kidane said, what has improved in the last decade or so is an attempt to provide paramedics with “guidelines and guardrails.”

“It is so that paramedics and EMTs can treat patients more successfully and recognize some of the pitfalls if these treatments are not handled with extreme caution,” he said.

Richmond Police Department policy: Officers should ‘continuously monitor’ a restrained person for signs of medical distress

RPD’s current policy manual states that, “While it is impractical to restrict an officer’s use of reasonable control methods when attempting to restrain a combative individual, officers are not authorized to use any restraint or transportation method which might unreasonably impair an individual’s breathing or respiratory capacity for a period beyond the point when the individual has been adequately and safely controlled. Once the individual is safely secured, officers should promptly check and continuously monitor the individual’s condition for signs of medical distress.”

Richmond Police Officers Association (RPOA) president Sgt. Ben Therriault told Richmondside that, generally, when officers put someone in a physical restraint device like the one used on Lopez it is typically because they are too combative to be taken to a hospital or jail any other way. Before such devices were available to police officers, he said, officers had to use their own physical force to get an uncooperative person onto a gurney or in a police car.

When asked if there are times when officers can remove such a restraint, Therriault said it’s a judgement call. 

“There really is not just one answer,” he said. “I, personally, am like, once you go into that thing, you’re not coming out. You are probably not coming out unless there’s some medical issue because (officers) are going to want the same amount of people that had to put someone into that (restraint) to be present when you take them out.”

Hirsch, the paramedic, told investigators he sedated Lopez because he believed Lopez posed “a danger to others and himself” and said he had heard from officers that Lopez was “on something.” 

“It seemed like some sort of stimulant,” Hirsch told investigators when asked what he thought Lopez was intoxicated with, once he was able to observe him. “He didn’t seem like he was exhausted, it seemed like he was still very agitated.”

The audio recording of the interview did not include a brief interaction that can be seen and heard on the police body camera footage: As paramedic Hirsch and his partner arrived at Lopez’s house, Richmond Police Officer Michael Ricchiuto says that Lopez “needs the shot thing,” while gesturing like he was pushing down on a syringe. He later can be heard saying it a second time.

Regardless of anything an officer might say on scene, Therriault said, it’s up to paramedics to decide if someone needs to be sedated, although he said that officers can relay pertinent information to paramedics in real time during incidents, like the Lopez case, where officers have exhausted all other uses of force such as holding the person down with their bodies or using batons or tasers, all of which were tried on Lopez. 

“They (sedatives) work really fast,” he said. “If you are fighting someone and they are in this kind of super-human strength mode, which does happen and is usually connected in my experience to a combination of things, like they’re having some kind of mental health thing going on plus something else on board. That is key in locking in whether someone is being impossible to control even with a taser or hitting someone with a baton.”

If less invasive control methods fail, Therriault added, officers can’t do much else due to the risk of injuring someone.

“It’s really hard,” he said. “Because you are trying to force something to happen, but you also have to do it with the least amount of harm to somebody.”

‘Is he breathing,’ one officer asks

Hirsch explained to investigators that it would typically take “three to five minutes” for an aggressive patient to respond to a 5 milligram dose of midazolam.

Police body camera footage shows that Lopez appeared to become calm within a minute of being given the sedative. Toxicology records would later show that he had cocaine in his system — a factor the coroner ruled was a contributing factor to his death.

The police video captured Lopez making an audible grunt 43 seconds after he was injected and five seconds after paramedics had left him on his living room floor while they fetched a tarp to help lift him onto a gurney. 

Eighteen seconds later, Richmond police officer Cedric Tagorda is heard on camera asking, “Is he breathing?” 

As Hirsch reentered the home, he can be heard asking, “Is he not breathing?” 

Tagorda, who a year later would find himself in a similar situation with Gutzalenko, who stopped breathing after being injected with the same drug, then seems to correct himself.

“Nah, I’m just making sure because his face was all on his side,” he said. 

Hirsch then said, “Wow, that was fast.”

The video shows Hirsch, his partner and several police officers and Richmond Fire Department personnel then moved Lopez onto the gurney, as Lopez’s head hung downward. 

They rolled the gurney out and wrapped the tarp around Lopez, leaving him sitting up with his head slightly hanging down.

Hirsch told investigators who interviewed him that evening that he couldn’t see if Lopez was still breathing due to how  “tied up” he was.

But in the same interview, he says: “We knew his airway was good, he was moving around. I specifically remember as we were walking down, asking one of the officers if he was still breathing, he said, ‘Yes, still breathing.’ ”

Hirsch told investigators he had used midazolam about 10 to 15 times during his, at that point, three-year career as an AMR paramedic and never had anyone’s heart stop. Hirsch apparently still remains employed by AMR where he works as an operations supervisor/captain, according to his LinkedIn.

“I’ve never had an airway compromised, I’ve never had anyone go into cardiac arrest,” he told investigators. “It’s a very safe drug, that’s why we have it.”

AMR declined to answer questions about Hirsch. Hirsch, when contacted by this reporter in 2023 via a social media message app, said he did not recall the case. 

As of now, the company and AMR paramedic Damon Richardson, the paramedic who injected Gutzalenko, are named in a lawsuit filed by the Gutzalenko family.  Tagorda is also named in the lawsuit. None of the officers in that case were held responsible, and neither Richardson nor Hirsch were ever charged with a crime.

Richmond’s former police commission investigator called sedative use ‘dangerously reckless’

While investigators for the district attorney’s office and Richmond’s community police commission (CPRC) noted the use of the sedative in their reports about Lopez’s death, only the CPRC report questioned its use. Neither questioned whether it could have contributed to his death.

Then CPRC’s investigator Jerry Threet, a lawyer who was a former San Francisco deputy district attorney and director of Sonoma County’s Independent Office of Law Enforcement Review and Outreach, wrote that he was troubled by the sedative’s use. (Threet resigned from the commission in 2024 after criticizing its overall operation.)

“While the IO [investigative officer] believes that [Richmond police officer] Ricchiuto’s recommendation to AMR personnel that they administer a sedative to Lopez at the conclusion of the struggle was inappropriate and dangerously reckless, the IO also has concluded that this action is not within the purview of the CPRC and thus makes no recommendation in this area. However, Ricchiuto’s actions in this regard likely exposed the City to the risk of liability in this matter.”

Threet also said that three officers used unnecessary force: Kenneth Ferraro, who first tackled Lopez and put him into a chokehold; Ricchiuto, for striking Lopez with his baton and using a taser on him; and Officer Douglas Frevele, for placing his weight on Lopez’s neck area while Lopez was restrained and positioned face down.

In the aftermath of Lopez’s death, RPD’s Office of Professional Accountability’s (OPA) internal investigation, which concluded in January of 2023, found that only Ferraro used unreasonable force — by applying a carotid hold. It cleared the 10 other officers from any wrongdoing.

According to department employment termination records, Ferraro was injured during the struggle with Lopez and eventually retired in June of 2021 after being on disability leave for more than a year. The department investigator was “unable to conduct a follow-up interview with him,” according to records. Frevele retired in 2022 after being on disability leave. Only Ricchiuto remains employed by the department.

Tomorrow: Jose Luis Lopez’s family members recall his happy childhood followed by a period marked by arrests, mental health and substance abuse issues. They’re still struggling to understand his death five years later and wonder if anything will change as a result.