Family of man who died in Richmond police custody challenged cause of death report

Petronila Fernandes and her husband Filipe Fernandes said they spent two years not knowing what happened to her brother Jose Luis Lopez, who died after being restrained by Richmond police officers and forcibly sedated by a paramedic.

Lopez, who lived in Richmond, and Ivan Gutzalenko, a 47-year-old Concord man who Richmond police were trying to detain, are among 16 people statewide who died over a 10-year period after being given the drug midazolam by paramedics during police calls, according to an Associated Press investigation.

After Lopez was removed from life support on March 19, 2020, just three days after his 40th birthday, the family said they lived a “nightmare” of trying to get his body to his home country of Nicaragua, eventually succeeding in October of 2022, just one month before the Contra Costa County District Attorney’s Office told them that no charges would be filed against the 11 officers who were at his home during the March 17, 2020 confrontation.

Then, in November of 2022, the couple met with the DA’s office Chief of Inspectors Arnold Threets (not to be confused with the similarly named former Richmond citizens police commission investigator Jerry Threet), a former 25-year Richmond police officer who joined District Attorney Diana Becton’s office in 2019.

At that meeting Threets said that Lopez died of “excited delirium due to acute cocaine toxicity,” echoing the cause of death ruling made by the Contra Costa County coroner.

Filipe Fernandes said he questioned whether excited delirium caused the death, saying he had read that this theory had been rejected by medical experts. 

Excited delirium, often categorized as sudden death by cardiac arrest preceded by agitation, aggression and paranoia, is a controversial diagnosis that is now longer endorsed by organizations such as the American Medical Association, American Psychiatric Association, and most recently, the National Association of Medical Examiners.

“How is it possible if that isn’t scientifically proven?” Filipe Fernandes said he repeatedly asked Threets and DA investigator Janet Era, who acted as their Spanish translator. “How is it after days that a person is still intoxicated that it kills them?”

Fernandes said it was his understanding that excited delirium deaths refer to cases where an individual dies in the midst of a struggle, and medical experts agree.

While the coroner’s October 2020 cause of death report cited a 2009 American College of Emergency Physicians white paper about excited delirium, in 2021 the American Medical Association released a new policy opposing the diagnosis, saying that “excited delirium has been misapplied and diagnosed disproportionately in law enforcement-related deaths of Black and Brown individuals, who are also more likely to experience excessive sedative intervention instead of behavioral de-escalation.”

“For far too long, sedatives like ketamine and misapplied diagnoses like ‘excited delirium’ have been misused during law enforcement interactions and outside of medical settings — a manifestation of systemic racism that has unnecessarily dangerous and deadly consequences for our Black and Brown patients,” AMA President Gerald E. Harmon wrote. “As physicians and leaders in medicine, it is our duty to define the medical terms that are being used to justify inappropriate and discriminatory actions by non-health care professionals.”

The diagnosis has also locally come under scrutiny, for example in the case of Angelo Quinto, a 30-year-old Antioch man who lost consciousness while being restrained by Antioch police on Dec. 23, 2020 and died later at a Sutter Delta Medical Center.

In the aftermath of Quinto’s death, California adopted Assembly Bill 360 in October of 2023, eliminating the term “excited delirium” as a valid medical diagnosis or cause of death by coroners, medical examiners, physicians, or physician assistants and stating that it was not to be referred to in police reports by officers.   

Richmond’s 2025 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 at issue as ‘excited delirium.’ “

Other agencies, both locally and nationally, adopted policies to stop using excited delirium as acceptable causes for arrest. In 2021, BART announced it would strike the term from its police manual while in March of 2023 Minneapolis police, the department found responsible for George Floyd’s murder, which took place just two months after Lopez died, banned excited delirium training for officers while also barring officers from directing paramedics to inject sedatives into individuals they believe are in such a state. 

According to Dr. Senai Kidane, director of Contra Costa County Health’s Emergency Medical Services, which oversees practices by paramedics, the term “excited delirium” was removed and changed to “severe agitation” in late 2021 and early 2022.

“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,” Kidane told Richmondside.

Who was Jose Luis Lopez?

Lopez’s sister shared some insights about her brother that might explain some of the life circumstances that might have led him to end up in a struggle with police that day in 2020.

Lopez was born in Nicaragua in 1980, the fourth of eight brothers and sisters growing up in an idyllic neighborhood on the island of Ometepe, in Lake Nicaragua in the southwest part of the country.

“He had the childhood that kids these days don’t have, walking around, talking to his neighbors who would give them fruit from their trees,” Fernandes recalled. “In his education, he was outstanding and responsible (and) he always had a good character about him.”

But their parents’ divorce shattered the family.

“The beautiful, stable, middle-class family we had just imploded,” she said.

Their mother began a new relationship and turned her attention away from Lopez and his siblings, she said.

“The situation with our parents affected him very much,” she said. “He was very close to both of them … I think it psychologically affected him a lot.”

Lopez eventually finished his studies at the Instituto Tecnico in Granada, becoming an industrial electrical technician.

Around 2000, their father, who had by then moved to the United States, started getting things in order to bring Lopez and his siblings to California. Eventually, the family settled in Richmond.

Lopez had an accident at work in 2001. A piece of plywood fell and struck his head, knocking him unconscious, family members said. It was an injury that his father felt changed him, according to his sister.

Petronila Fernandes began hearing rumors that her brother was abusing drugs.

“People would tell me that my brother would be on drugs, but I can’t confirm something that I’ve never seen myself,” she said.

Sometime in 2007, Lopez was convicted of domestic violence. While serving a year in Contra Costa County’s Martinez jail, he told family members he was the victim of violence at the hands of other inmates. He eventually was released in 2019, according to court records.

Prior to the domestic violence case, Fernandes said, his then-partner tried to help Lopez find help for his mental health.

After his death, as she collected his belongings a call came in on his cell phone from the Contra Costa County Department of Health: His request for help had been approved.  Lopez could receive housing and mental health resources.

“I told them he isn’t with us anymore,” she said through tears. “He’s dead.”

Lopez’s sister just wishes she could have said goodbye

In the five years since her brother’s death, Petronila Fernandes has continued to search for answers about what happened. She received medical records from Kaiser in 2023 in an attempt to piece together Lopez’s last moments, but due to the statute of limitations on filing a wrongful death lawsuit, the family has no legal recourse when it comes  to finding “justice” for his death.

“It’s hard because I wish I could have said goodbye,” she said in a 2023 interview with this reporter, sobbing inside of the San Pablo library where she often goes to use the internet. “We were the closest of all of our siblings. People would call us twins because that is how close we were growing up.”

Her Facebook profile is filled with photos of Lopez and news articles related to his case. She also began regularly attending a church in Richmond that is led by the pastor of the church her brother attended.

She hopes her brother’s medical records give her a better idea of what condition doctors at Kaiser found Lopez in when he arrived there though, she admitted, she finds the information hard to understand without any medical knowledge.

She said that gathering records has been difficult, given the language barrier and her lack of knowledge of technology or how to formally request public records.

“I feel helpless. It’s that feeling that you want to just scream out for help but you have no idea where help is coming from,” she told Richmondside in April. “All I have is the support of my husband.”

She says she has battled waves of depression, one that initially came in the wake of her brother’s death and then again after finding out that no one would be held criminally responsible. She is currently taking high blood pressure medication and seeing a therapist and says she is finally feeling somewhat herself again.

She often wishes she could have done more for her brother, a person she said had his faults but who was also loved by many people in the Richmond and San Pablo Latino community.

“Those who knew him were in shock when it happened, they couldn’t believe it and still don’t believe many of the negative things that were said about him,” she said, adding that some local businesses and taquerias helped collect donations to return his body to Nicaragua.

Richmond police now can call mental health crisis program A3 for non-criminal incidents

Richmond has, in recent years, been revising its approach to policing, for example by reallocating money from the police department budget to establish community services such as ROCK (Reach Out with Compassion and Kindness), a non-emergency mental health crisis response team.

Additionally, Contra Costa County implemented its A3 program (Anyone, Anywhere, Anytime) — which grew from a pilot program in 2021 to a 24/7 emergency service in December of 2023. A3 dispatches trained mental health professionals, rather than police, to non-criminal mental health and substance abuse emergencies.

Richmond police Lt. Ben Therriault said that since A3’s launch Richmond officers have increasingly relied on it.

“Like with anything in a bureaucracy, as things go along, it takes time to change people’s mind because for a long time, like when I first started (in 2008) we would have supervisors who would ask us to get a sense of these calls and are we the best tool for them in all cases? No. Sometimes we’re the necessary tool because no one else is going to go there.”

Therriault, who is president of the police union, said it is up to police managers and supervisors to convey the options to officers and is up to officers to evaluate whether A3 should respond.

“Again, you don’t have to do it (call A3) during every single time because there is nothing saying ‘Thou shalt call A3’ but I will say this, most officers prefer to do that and I think a lot more have shifted that way in the past couple years,” he said.

From September of 2023 to the end of August of 2025, A3 received 41,525 crisis center calls, 2,553 of which came from Richmond, according to county A3 statistics.

During that time, of the more than 770 calls for in-person crisis assessments, Richmond police were not needed for 579 of those calls — about 75%, according to that data.

County health’s Kidane said that it has been fantastic to see A3’s growth. 

“I would say this partnership includes the entire 911 community,” Kidane said. “With the development of A3, they have established partnerships with law enforcement agencies and their protocols in many, if not all, of the law enforcement dispatch centers.”

Those dispatch centers, he said, determine which agencies, whether law enforcement, paramedics or A3, will handle a call for help.

Although Richmond began developing the ROCK program in 2020 in an attempt to “reimagine public safety,” the group’s progress was slowed, in part, due to a dispute with the police union, which argued that those crisis intervention positions should be part of their union. The dispute was recently settled in a public hearing, but the police union said it will file an unfair labor practice complaint against the city with the California Public Employees Relations Board (PERB).

Additionally, there has been an effort by some members of the city’s citizens police commission (CPRC) to get the power to automatically launch investigations into all cases where officers use the physical restraint device that was used on Lopez and cases involving tasers and police dogs. (A taser was used on Lopez, and a police dog was present.) It also wants to extend the filing deadline for citizens to file complaints from 120 days to one year. The Lopez family didn’t know about the CPRC or that they had a right to file a complaint until the deadline had passed.

While approaches in Contra Costa County and Richmond such as A3 and ROCK represent hope, such alternatives are not deployed in emergencies such as Lopez’s, which involved an accusation of domestic violence.

For Petronila, the city’s shift to alternative policing methods and more police oversight with the CRPC is bittersweet. Had she known about the CPRC, she feels her family would have had more answers about her brother’s death sooner and at the least would have had a chance to be heard. 

She hopes that details of the CPRC complaint process can be better communicated to families who are impacted like hers was so that those in the community know their rights.

“There should be an indefinite window for (filing) complaints,” she said. “These (CPRC) recommendations open the door for a lot of changes because the people in this community, people like me who have language barriers, don’t know where to go.”

Yet, through all of the difficulty, she is determined to stay strong and improve her health so that she can keep her brother’s memory alive and bring light to his case so that what happened to him doesn’t happen to others.

She’s also found solidarity with other families who have experienced the death of a loved one during a police encounter, people such as Robert Collins, Quinto’s father, and Rick Perez, the father of Pedie Perez, a man who was shot to death by Richmond police in 2014. 

“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.”

In a written statement to Richmondside, police spokesman Lt. Donald Patchin said that the department’s “highest priority is to resolve encounters safely, respectfully, and with professionalism.”

“We recognize the seriousness of these incidents, and we extend our deepest sympathies to all who have been affected,” he wrote. “At the same time, the City remains committed to transparency, accountability, and to ensuring that the community has confidence in the professionalism of its Police Department and in the systems designed to safeguard public safety.”

Tomorrow: The case of Ivan Gutzalenko: How did a registered nurse suspected of stealing an energy drink end up dead 90 minutes later?