An off-duty nurse’s behavior startled onlookers. He died 90 minutes after police arrived

A year after Richmond resident Jose Luis Lopez died after being forcibly injected with a sedative while heavily restrained by police, a similar fate befell Ivan Gutzalenko, who was given the same drug by a paramedic while he lay bleeding from his hand and mouth at the corner of San Pablo and Solano avenues. 

On March 10, 2021, the registered nurse, a 47-year-old father of two from Concord, whose family members later said had struggled for years with mental health and alcohol abuse issues, had been seen acting erratically, walking in and out of several businesses. When police arrived, he collapsed on a sidewalk, telling an officer he was having trouble breathing. 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.

As police struggled to handcuff him while they held him down, a paramedic decided to inject him with a sedative called midazolam, and he soon stopped breathing. He was dead within about 90 minutes, a review of public records showed. Contra Costa County authorities would later rule his death was accidental, a result of being restrained while under the influence of methamphetamine.

According to a 2024 Associated Press investigation, from 2012 to 2021 there were 16 deaths statewide in which midazolam, also known by the brand name Versed, was given to people in police custody. These included Lopez and Gutzalenko, who had previously worked as a burn unit nurse in San Pablo.

In 2022, Gutzalenko’s family filed a civil rights lawsuit in federal court, suing the city of Richmond, the police chief, the three officers involved, the ambulance company, American Medical Response, and the paramedic who injected him. (Neither paramedic in the two Richmond cases were charged with any crimes.)

According to federal court records filed on Aug. 12, the Gutzalenko case is tentatively set to begin trial proceedings on Feb. 2, 2026.

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 midazolam, but information Richmondside obtained through a Public Records Act (PRA) request provides some insights.

According to the data, AMR personnel 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 administered midazolam more than 4,000 times from 2018 to 2022, according to a report 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-related injections were given but was told by a county spokesperson that the county does not have records on which local law enforcement agencies were involved.

Police officer: ‘Hey, he’s getting blue in the face’

What started as a petty theft police call just after 10:30 a.m. on that day in 2021 quickly escalated into a medical emergency that ended in Gutzalenko’s death less than two hours later.

According to police records, multiple people called 911 to report that a man, later identified as Gutzalenko, had entered nearby stores and was “causing a ruckus.”

Callers said that Gutzalenko had ping-ponged around the block, going into the former Richmond Furniture Store on the 12600 block of San Pablo Avenue, “bleeding on merchandise,” apparently from a minor injury, before crossing the street and entering a 7-11 and then Rose and Mike’s liquor store, where a witness said he took an energy drink without paying.

Dispatchers noted that one of the callers, a business owner, was hard to understand but they thought he was telling them that Gutzalenko was “tearing up his store,” a narrative later repeated by officers who were relaying information to each other and paramedics at the scene.

In dispatch audio reviewed by Richmondside, another caller can be heard saying that Gutzalenko appeared to either be intoxicated or having a mental health crisis and said he confronted Gutzalenko outside the 7-11 and “chewed him out”  because he saw him take the drink from Rose and Mike’s without paying.

In police body camera footage viewed by Richmondside, Richmond police officer Tom Tran was the first officer to approach Gutzalenko at about 10:41 a.m. as he walked south on San Pablo Avenue toward the Solano Avenue intersection.

“Are you OK?” Tran asked.

“No,” Gutzalenko responded, falling to the ground, writhing around.

“Can you do me a favor and put your hands behind your back?” Tran asked, repeating the request a handful of times.

“No,” Gutzalenko said.

Gutzalenko struggled to get up and collapsed multiple times before ultimately falling down in front of the parking lot of C&D Auto Repair and Towing. Tran told dispatchers he believed Gutzalenko was “10-51,” police code for someone under the influence of narcotics.

“I can’t breathe,” Gutzalenko grunted as he lay on the ground, Tran crouched next to him.

“Just lay on your side,” Tran responded, reassuring Gutzalenko that an ambulance was on its way.

“Is he 5150 or what?” asked Officer Mark Hall, who arrived two minutes after Tran. 

“No. He said he can’t breathe,” Tran said.

As Tran attempted to position Gutzalenko on his side, in what he later described in his report as a “recovery” position, Hall went through his pockets and found his ID in a wallet.

“The ambulance is on its way and they’re going to take care of you,” Tran said.

“Thank you officers,” Gutzalenko responded.

As he lay on his side with his left hand extended and a bleeding right hand held above his head, Hall asked Gutzalenko what may have caused his breathing difficulties, asking if he had ingested any substances and why he had dried vomit on his shirt and what seemed to be a bruise on his head.

“We’re trying to get you the right treatment,” Hall said, asking Gutzalenko if he had taken fentanyl, heroin, methamphetamine or cocaine and assuring him that he wouldn’t be taken to jail if that were the case. “What kind of drugs do you use?”

“Just weed,” Gutzalenko responded.

As the two officers continued to question Gutzalenko, while reassuring him that paramedics were coming, they were joined by Officer Cedric Tagorda. Tagorda was among the 11 Richmond police officers who were present in 2020 when Lopez was restrained during a police struggle and given a sedative by an AMR paramedic. Tagorda had dispatchers search Gutzalenko’s background and spoke to the paramedics, telling them to grab a spit hood because Gutzalenko was apparently spitting out blood. Paramedics can be seen in body camera footage bringing over a gurney.

Gutzalenko attempted to get up multiple times as Tran and Hall held him down, continuously asking if he had a medical condition. Hall suggested they place him on a 72-hour psychiatric hold (“5150”). Once Gutzalenko heard that, he became more agitated and said he had no medical condition and it was illegal to place him under a hold.

In California, a person can be placed on a 72-hour involuntary psychiatric hold if they are deemed to be a danger to themselves, a danger to others, or gravely disabled due to a mental health condition, with the hold based on probable cause that the person meets these criteria. Police officers, licensed mental health professionals, and certain other designated professionals such as paramedics can initiate a 5150 hold, after which the person must be taken to a designated psychiatric facility for evaluation. The 72-hour period begins when the person arrives at the facility, not when the hold is first placed, and during this time mental health professionals assess whether the person meets the criteria for continued involuntary treatment.

“Why are you doing this to me?” Gutzalenko cried out as Tran and Hall held on to him while AMR paramedic Damon Richardson tried to bandage his bleeding hand. Eventually, Tagorda began holding Gutzalenko’s legs.

“We’re trying to help your cut, man,” Tran told him, as Hall held Gutzalenko’s left hand, extending it while twisting it in the opposite direction.

“You’re hurting me,” Gutzalenko said, squirming on the ground and knocking Tran’s bodycam off. “God damn you.”

“Get ready to get tased, Ivan,” Hall said as Gutzalenko pleaded for him not to. “Then you better listen to us now or you’re going to get tased. Quiet!”

As Gutzalenko repeatedly said “please” to those around him, Hall asked the other officers and the paramedic how they planned to place the 6-foot-tall, 200-pound Gutzalenko onto the gurney. The paramedic, Richardson, suggested that he administer midazolam while the officers held him down.

Officers then attempted to handcuff Gutzalenko while Hall at one point suggested that officers pepper spray him. They handcuffed him after a minute of struggling.

Just moments after Gutzalenko was handcuffed, he stopped moving and grunting and could be seen on the video breathing heavily, with his stomach rising deeply. Hall said that he believed Gutzalenko was faking being unconscious.

Richardson returned with a syringe containing what was later determined to be 5 milligrams of midazolam. Tran pulled Gutzalenko’s collar down to expose his neck.

“You want to get him on this gurney?” Tagorda asked just as Richardson injected Gutzalenko in the neck. “Alright. Nevermind. You got that. That’s the good stuff.” 

Richardson later explained to investigators that he injected that amount because he didn’t have enough time to get 10 milligrams — the amount recommended by Contra Costa Health for an intramuscular sedative dose.

About one minute after Gutzalenko was injected, those at the scene noticed he appeared to have stopped breathing.

“Ivan, are you there, buddy?” Tran asked, patting Gutzalenko’s chest after a group of medical responders and officers placed him on the gurney.

“Hey, he’s getting blue in the face,” Tagorda noted.

As soon as the first responders realized Gutzalenko wasn’t breathing, the handcuffs were removed, and he was placed on a LUCAS device, a mechanical CPR system.

Hall and Tagorda could be heard saying they needed to keep their cameras on while Tran seemed to become upset. Both Hall and Tagorda can be heard assuring Tran that he had done nothing wrong. The officers anticipated they would be sequestered for questioning.

“Tran, you didn’t do anything wrong. He’s under the influence of something,” Hall said. “We didn’t use any chokeholds, we used arm controls. So just relax, I know it’s fucking concerning.”

“I just want him to be good, you know?” Tran responded.

As Tran watched paramedics attempt to revive Gutzalenko, Hall can be heard telling Tagorda he had never been in such a situation.

“I have,” Tagorda responded, possibly referring to the Lopez incident a year earlier.

As Richmond Police Lt. Matt Stonebaker arrived, Tagorda gave him an update, stating that Gutzalenko was “destroying” a nearby store and that the group did not use force on him and that he was “obviously inebriated.” He said paramedics had to give him “the thing to make you calmer.”

According to Tagorda’s bodycam, which was still recording after both Tran and Hall had turned theirs off, Stonebaker can be heard telling officers they were just “holding his arms” and that the paramedic made the decision to administer the sedative.

Gutzalenko was taken to the Alta Bates Summit Medical Center in downtown Oakland where he was pronounced dead by emergency room doctors just before noon.

County coroner rules death “accidental,” linked to methamphetamine use

The Contra Costa County Coroner’s Office released the cause of death in March of 2022, stating that it was accidental and caused by “prone restraint asphyxia and cardiac arrest while under the influence of methamphetamine.” 

The report stated that traces of midazolam and methamphetamine were discovered in his blood. (In Lopez’s case, the coroner’s reports, including a toxicology report, did not mention that he had been sedated with the same drug.)

All three officers involved in the Gutzalenko case were placed on administrative leave after he died, as is standard with in-custody deaths.

Ultimately Hall retired after being injured in February of 2023. Tran and Tagorda were reinstated, both are still Richmond police officers, according to city employment records.

More than two years after his death, the Contra Costa County District Attorney’s office exonerated the three officers, saying there was “reasonable doubt” that Gutzalenko’s death was “caused by the administration of the sedative and/or the drugs at the hospital.” 

The district attorney’s Law Enforcement Involved Fatal Incident (LEIFI) report released in May of 2023 noted that “consistent with the limited degree of force utilized, the forensic pathologist concluded there was no evidence of neck compression or breathing restraint.” 

Gutzalenko’s death came almost exactly a year after Lopez died under similar circumstances and about 10 months after the death of George Floyd in Minneapolis — a case that drew international attention to how police physically restrain suspects.

According to city records reviewed by Richmondside, the city’s Office of Professional Accountability (OPA) report diverged slightly from the city’s Community Police Review Commission’s (CPRC) decision on whether the three officers acted according to the department’s policies and procedures when they were trying to detain Gutzalenko. 

The OPA, which was established in 2016 in the aftermath of the officer-involved shooting death of Pedie Perez, operates under the Richmond Police Department as the internal investigations unit. Previously, the office, which was touted as a national oversight model, was led by Eddie Aubrey, a former Los Angeles police officer, who was hired during the office’s inception as a “civilian” manager until his departure in 2024. Currently, it is led by Richmond police Lt. Joseph England.

A year after Gutzalenko’s death, in 2022, the OPA ruled that Tran, Hall and Tagorda didn’t apply any unreasonable force. While the CPRC’s public summary of the case concurred with that decision, it did, however, single out Hall, saying he did not follow department policy, which directs officers to attempt to deescalate such situations.

The CPRC public summary, which was published in January of 2024, recommended that the department conduct a “comprehensive review” of incidents involving the use of sedatives and the role officers have in deciding to administer them and called for “training its officers on the appropriateness of such injections in crisis situations and set out clear rules to guide officers’ actions in such incidents.”

How Richmond police are trained to deescalate crises

It is unclear if the department complied with the CPRC’s request for a review of sedation policies, and Richmondside did not get any response from several commissioners it contacted for comment. Richmond police spokesperson Patchin told Richmondside that the department could not comment on Gutzalenko’s case due to the ongoing lawsuit, but he said only paramedics make the decision to sedate someone.

A March 2025 Richmond police training bulletin obtained by Richmondside offered updated guidance on responding to individuals experiencing mental health crises, outlining how officers should provide immediate behavioral health support and connect individuals to ongoing care and resources, for example by engaging the county’s crisis intervention team, A3.

Among the reminders in the memo is a note to “use deescalation techniques and consider alternative responses.”

Patchin said that officers are extensively trained in deescalation techniques.

“Significantly, the City’s officers go through extensive training that focuses on resolving situations in an amicable manner and without the need to use any force. In fact, every one of the City’s officers is required to undergo a rigorous training program that focuses on the use of deescalation tactics before they are ever sworn as police officers,” Patchin said in a written statement to Richmondside. “That training continues throughout the entirety of every officer’s career, including attending mandatory retraining and evaluations based upon the curriculum mandated by the State of California’s Commission on Peace Officer’s Standards and Training (POST).”

Richmond police Sgt. Ben Therriault, president of the police officers union, told Richmondside that such training continues regularly.

“There is a constant cycle within the subject,” Therriault said. “There’s always a minimum eight-hour block set for crisis intervention which touches upon deescalation. But deescalation is also touched on, most of the time, in the use-of-force updates and defensive tactics where we practice actual use of force.”

The CPRC recently won approval from the Richmond City Council to update a number of its policies in its effort to expand its oversight over the police department, though the city still has to negotiate the proposed policy changes with the police union.

The CPRC’s policy changes originally included a request to automatically review incidents involving body-restraint devices but that wasn’t included in the recommendations that the council ultimately approved.

Police Chief Bisa French, in her March 2024 response to the CPRC’s January 2024 summary report on the Gutzalenko death, commented on its recommendation that the department evaluate officers’ use of chemical restraints such as the sedative midazolam, stating that officers have “no role in that decision.”

“This is a decision that is made solely by medical personnel,” French wrote. However, in Richmondside’s review of police body camera video recorded during the 2020 Lopez incident, a Richmond police officer can be heard telling paramedics at least twice that they “need the shot thing,” at one point gesturing like he was pushing a syringe plunger.

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 in a written statement. “These licensed medical professionals — typically paramedics — are privately employed and operate entirely independently of the City and its Police Department. Their medical judgment is not directed, influenced, or overseen by the City.”

AMR declined Richmondside’s request for an interview about its sedatives policies, citing the Health Insurance Portability and Accountability Act (HIPAA) that prevents the disclosure of protected health information.

Gutzalenko case ‘fell through the cracks’ of CPRC’s investigation process

According to sources close to the CPRC, there was a delay in its review of Gutzalenko’s death because former CPRC investigator Jerry Threet, a lawer and former San Francisco city deputy attorney, did not immediately investigate it after the commission was notified of Gutzalenko’s death in 2021. (The commission is tasked with investigating all in-custody deaths, and there is often a backlog of cases in general.)

During the CPRC’s June 7, 2023 meeting, commissioner Dan Lawson, who had been appointed three months earlier, had asked Threet about the Gutzalenko case. Threet responded that he wasn’t notified about the case and did not recognize Gutzalenko’s name but would “look into it.”

Richmondside requested Threet’s investigative report on the Gutzalenko case but the city did not provide it. (In the Lopez case, the city released the CPRC’s investigative report after Richmondside submitted a Public Records Request.)

In an interview with Richmondside on Tuesday, Threet said that CPRC’s investigation of the Gutzalenko case “fell through the cracks” due to administrative staffing issues.

“The admins that were provided to the commission (during my time) were always part-time people that actually had a primary assignment with something else or sometimes even more than one primary assignment,” Threet said. “There was an admin who was eventually terminated because she was not performing her duty appropriately. There were periods where we had gaps.”

Threet said he, and the CPRC as a whole, was notified initially of the Gutzalenko incident but that the case was never added to its case log.

Typically, he said, the CPRC is notified by the OPA of an in-custody death but will wait until the LEIFI report and subsequent criminal investigation reports are issued by the district attorney’s office before it conducts its own investigation. This is to ensure due process in any potential criminal case that might result. In the Gutzalenko case, the LEIFI report was issued in May of 2023.

“So there’s nothing requiring the administrative investigation to wait until the criminal one is done but that’s typically what they do,” Threet said, adding that if officers are ordered by the chief to comply with administrative investigations — like the CPRC and OPA investigations — any answers they give those investigators can’t be used in the criminal cases against them.

As to the CPRC’s recommendation that the department review the role of RPD officers in sedation, Threet said that it commission did this because it was the second death in which sedation was used. He said there was “some back and forth” and “resistance” from the department, which said officers have no role in that decision.

“In the Jose Luis Lopez case, it’s obvious on the body-worn camera. In light of that, you can’t say that (officers never ask for sedation.) I mean, the department can make that representation that that’s the policy but that is always what happens. That’s where that recommendation (to review sedation policies) came,” he said.

Referencing Richmondside’s story about Lopez and AMR paramedic Rob Hirsch’s statement about what officers told him about Lopez’s physical and mental state, Threet said officers ultimately can influence paramedics’ decisions by what they say. (In a ruling related to the Gutzalenko’s family’s lawsuit, a judge also questioned the role paramedics play, suggesting that by injecting suspects they’re acting on the behalf of police.)

“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. 

Threet stirred up some controversy when he resigned from his CPRC role in 2024, sending an email to a number of city officials stating that newly appointed commissioners were not objective and “ignored evidence.” 

Read the entire five-day Restrained and Sedated series.