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.
A federal civil rights and wrongful death lawsuit filed by the family of a man who died after being forcibly sedated during his arrest in Richmond accuses the paramedic of improperly acting on behalf of police and says police officers applied excessive force and were inadequately trained in safe restraint practices.
The complaint, filed on behalf of the family of Ivan Gutzalenko of Concord, alleges that the city and Richmond police Bisa Chief French maintained unconstitutional policies that permitted excessive force and failed to train officers on positional asphyxia risks, pointing to three Richmond deaths involving similar prone restraint techniques: Alan Arce and Uriah Dach in 2008, whose families settled their cases for $250,000 and $1.5 million, respectively; and Jose Luis Lopez in 2020.
The lawsuit, filed by Gutzalenko’s Oakland-based civil rights attorney John Burris, also mentions Lopez, whose death was ruled as being caused by “excited delirium,” saying because there was not a standard coroner’s inquest and because Richmond police did not invoke proper protocol, it was a “cover up.” They’ve accused the Contra Costa County Sheriff’s Office and Richmond police of preventing the Lopez case from being heard in an inquest, a process by which the Contra Costa County Sheriff-Coroner’s Office appoints a randomly selected jury of citizens to review specific cases, such as in-custody deaths. (None of the officers and neither paramedic in the two cases faced any criminal charges.)
Richmond police spokesperson Lt. Donald Patchin told Richmondside in an interview that the department evoked the required Law Enforcement Involved Fatal Incident protocol in Lopez’s death, which by default includes a coroner’s inquest, and said 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 an inquest being done, we have no say in that.”
However, in the case of Gutzalenko, who died in March of 2021, a coroner’s inquest was held, with the citizen body agreeing with the coroner’s ruling that his death was accidental due to the “prone restraint asphyxia and cardiac arrest while under the influence of methamphetamine.”
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.
The lawsuit also alleges that American Medical Response, a private emergency services provider, failed to properly train paramedics Damon Richardson, who when he injected Gutzalenko 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 since changed its protocols. AMR declined Richmondside’s request for an interview.)
County, police have updated some protocols for people in agitated states
Dr. Senai Kidane, director of Contra Costa County Health’s Emergency Medical Services, told Richmondside some modifications were implemented in late 2021 and early 2022 in the wake of George Floyd’s killing (Gutzalenko died 10 months after Floyd) to address how in-custody patients are 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 modifications, he said, categorize the degrees of agitation while providing paramedics with guidance around the range of agitation they might encounter.
In the years since Gutzalenko’s death, Contra Costa County implemented the A3 program, which stands for Anyone, Anywhere, Anytime. It started as a pilot program in 2021 and became a 24/7 operation in December of 2023. One of its purposes is to send trained mental health professionals, rather than police, to mental health and substance abuse emergencies.
According to a March 2025 Richmond police training bulletin, officers were instructed that “engaging the A3 team may lead to more appropriate resolutions for individuals in crisis and can help reduce the need for law enforcement intervention.” The memo, however, stated that officers must be involved to ensure safety and cannot defer responsibility entirely to A3.
The training bulletin was issued in response to a July 2024 Ninth Circuit Court decision in Scott v. Smith involving the Las Vegas police and a man with a mental health disorder who died after being physically restrained by officers. The court ruled to deny qualified immunity to the involved officers, who they said applied excessive force.
The court ruled that an officer’s use of bodyweight compression on a mentally ill individual’s back and neck constitutes excessive force when the person is not suspected of a crime and poses no risk to officers or others.
Richmond police’s management team has requested a legal opinion from the city attorney’s office regarding how the Scott v. Smith decision might affect Richmond police procedures.
Judge asks: Did paramedic’s injection serve a police function?
One central point to the Gutzalenko lawsuit is the argument that Richardson acted as a “state actor” by working in concert with police rather than as an independent provider of medical care. In a filing opposing the defense’s motion to dismiss the case, Gutzalenko’s attorneys argued that Richardson decided to chemically restrain Gutzalenko to help officers complete his detention.
U.S. District Court Judge Edward Chen denied the defendants’ motion to dismiss in March of 2024, finding that factual questions remain as to whether Richardson acted under “color of law,” referring to the appearance of legal authority that may not exist.
“The fact that the decedent was not resisting or thrashing at the time Mr. Richardson injected the decedent with Versed (midazolam) 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 depositions conducted in 2024, some details emerged, with Richardson stating that as the only paramedic at the scene the decision to use midazolam was “his decision alone.” He acknowledged that he failed to aspirate the syringe before the injection and said he had heard officers discussing a psychiatric hold known as “5150.” He also said he believed Gutzalenko experienced a midazolam overdose based on the circumstances — though he didn’t tell anyone at the time.
According to the lawsuit, the family is seeking monetary damages, punitive damages against the individual defendants and policy changes by law enforcement and emergency medical response agencies regarding the use of force and chemical restraint procedures.
Burris told Richmondside in April that questions remain about how local police agencies train officers in the use of sedatives.
Burris is also the lead attorney in another midazolam injection lawsuit filed by Kareim McKnight, who was injected with the sedative after being arrested by San Francisco police while protesting the overturning of Roe v. Wade at a Golden State Warriors NBA finals game in 2022. McKnight, who was briefly hospitalized, is suing the city and county of San Francisco as well as five employees of the San Francisco fire and police departments.
“We’ve been pretty strongly against the use of this drug and the arbitrary reasons it’s used,” Burris said. “We don’t know if people are properly trained because there’s an arbitraryness to it. There’s supposed to be a supervisor but that’s not always the case.”
In a 2024 Associated Press investigation into lethal restraint deaths nationally, Honey Gutzalenko, who is a nurse, was one of various family members who questioned its continued use.
“They’re running around on the streets administering these heavy-duty medications that could be lethal,” she said. “It’s just not right.”
Gutzalenko, a burn unit nurse who “saved lives,” struggled with mental health, alcohol abuse, family said
As is required for in-custody death cases, the Law Enforcement Involved Fatal Incidents Protocol (LEIFI) protocol was activated, requiring investigations by the Contra Costa County District Attorney’s Office, the coroner and the Richmond Police Department.
Gutzalenko’s family members were interviewed just hours after his death by DA investigator John Garcia and Richmond police Sgt. Brian Hoffman, who visited his acquaintances, including Honey Gutzalenko, his estranged wife, with whom he shared two children.
According to those close to him, Gutzalenko had recently been prescribed Ritalin, a drug commonly used to treat conditions such as attention deficit disorders. They said it had made him behave erratically.
Transcripts from those interviews detailed the couple’s troubled marriage, his problems with alcohol and his career as a registered nurse.
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
Gutzalenko, also a registered nurse, said they met while working at a local health clinic in the 2000s.
The two were married in 2010 and had two children but had separated in 2018 and filed for a divorce, according to court records.
Gutzalenko had been arrested before he was married, according to court records and interview transcripts. He reportedly served a six-month sentence for a gun-related conviction, which was later expunged.
Though the couple was separated when he died, Honey Gutzalenko told investigators that she had a good co-parenting relationship with her husband, who she described as a “loving, kind man” who her kids were close to.
“Why?” she asked Garcia. “What happened?”
“OK, we’re not sure, uh, what exactly, uh, happened,” Garcia replied, according to transcripts that said he told her authorities believed her husband died of “some kind of medical issue.”
“So he just kind of got disoriented this morning and, uh, and the Richmond Police Department contacted him,” Garcia explained. “He was kind of acting a little, you know, incoherent and stuff. And then, he had a medical episode, was transported to Oakland, to Summit Hospital. And they did everything they could to keep him alive.”
Garcia then told her that a colleague of Gutzalenko’s said he had complained he was suffering negative mental side effects from Ritalin.
“The (Richmond) police came and contacted him and he was acting very irrational. And he just wasn’t acting normal. And he went onto the ground and then he basically went into a cardiac episode. And then he got rushed to the hospital,” Garcia said.
“”
“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.“
— Honey Gutzalenko, the wife of a Concord man who died in police custody
During an interview in August with Richmondside, Honey Gutzalenko declined to answer detailed questions about the lawsuit but said that investigators did not mention the sedative to her when they came to her home.
“I wasn’t aware. They didn’t talk about it. They just ensured me that everything was done right and fine. I didn’t get that information and they didn’t go into that,” she said.
Richmond police spokesperson Patchin told Richmondside that investigators interviewing family members typically do not know the details of medical treatments that may have been given by medical personnel and thus would not be able to disclose such information. In addition, if they did know such specific medical details, they would be prohibited from sharing it due to Health Insurance Portability and Accountability (HIPA) Act rules that aim to protect patients’ privacy.
“We are not involved in that process. Regardless of the incident, we never say ‘These are the treatments that were provided,’ ” Patchin said. “We would never comment about a specific treatment.”
When asked by investigators about Gutzalenko’s history of alcohol abuse, Honey Gutzalenko responded that her husband would become confused and incoherent while drinking alcohol, often leaving their home for weeks at a time and staying with his mother or brother.
She told investigators she had never seen Gutzalenko take any illegal substances and while she didn’t know what Gutzalenko did after they separated, but he did a “good job” aside from calling in sick to work after drinking too much.
Honey Gutzalenko’s mother later told investigators that her son-in-law often exhibited mental health issues and believed he had experienced those issues unrelated to his alcohol use.
In describing her estranged husband to Richmondside, Honey said he was the type of father who spent quality time with his son and daughter.
“They went whitewater rafting. He took them to church. They went to festivals. He was teaching my son Russian and would bring him to his job as a worker’s comp manager, bringing him into the office and showing him what he did,” she said.
His death has been devastating for their children, who are now teens. Her son has since graduated from high school and has “turned it around” by taking Muay Thai classes. Her daughter, on the other hand, has struggled since his death, she said.
Gutzalenko was very “well-rounded” and very religious. Prior to working as a nurse, he attended an Eastern Orthodox seminary in upstate New York at the age of 19 but ultimately ended up pursuing a nursing career.
“It didn’t work out for him (at the seminary) so he figured the next best thing to do God’s work was to be a registered nurse,” she said. “He was an outstanding nurse who worked in critical care in the neighborhood where he lost his life.”
She said Gutzalenko worked at the former San Pablo medical center’s burn unit in the early 2000s before landing a job at Walnut Creek Kaiser.
“He was saving lives there for years (in San Pablo), helping firemen and police, saving their lives, and it’s such a shame that he lost his life right there in that same neighborhood,” she added. “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.”
A Facebook post she wrote on three days after he died expresses the impact his death had on their family:
“You never said I’m leaving, you never said goodbye. You were gone before I knew it, & only God knew why. A million times I needed you, a million times I cried. If love alone could have saved you, you never would have died. In life I loved you dearly, in death I love you still, in my heart you hold a place that no one could ever fill.
“It broke my heart to lose you, but you didn’t go alone, for part of me went with you, the day God took you home. Ivan, I love you & you left too soon. You gave me the most precious gift, our two beautiful loving children. This hurts us more than anything (we have) ever gone through. What we would give to be able to give you one last hug. To tell you how much you’re loved…You are the BEST DAD IN THE WORLD. Never forgotten & always with us.”
Read the entire five-day Restrained and Sedated series.
