The Gonzalez autopsy reports

The autopsy reports released on Friday undermine, if not override, the narrative that has grown up around the death of Mario Gonzalez in police custody last April.

Immediately after the City posted bodycam footage of the confrontation between Mr. Gonzalez and three APD officers, charges that Alameda police had wantonly killed the 26‑year‑old Oakland resident dominated the papers and the airwaves.  (We can only imagine what was being posted on social media, since we don’t use it ourselves.)

“Alameda police officers murdered my brother Mario,” Mr. Gonzalez’s brother, Gerardo Gonzalez, said in a written statement he read during a press conference outside City Hall.  “The officer killed him for no reason,” Mr. Gonzalez’s mother, Edith Arenales, added. “He’s not a criminal at all.  They don’t have the right to kill him. We’re human, not cucarachas.”

And they were not alone.  According to KTVU, “many” of the “family and civil rights activists from the Anti-Police Terror Project and Communities United for Restorative Youth Justice” who spoke at the press conference joined in “calling police ‘murderers.’”  (We’ve also heard the word used by public commenters during City Council meetings.)

At the same time as they accused the local cops of murder, the Gonzalez family, their attorneys, and various activists analogized the events in Alameda to the death of George Floyd, for which a Minneapolis police officer was convicted of second‑ and third‑degree murder and second‑degree manslaughter.

“The police killed my brother in the same manner that they killed George Floyd,” Gerardo Gonzalez said at the press conference, and others echoed his sentiments.

Julia Sherwin, one of the attorneys representing Mr. Gonzalez’s son in a potential suit for damages against the City, told KTVU that she “sees many parallels” to the George Floyd case.  And the San Francisco Chronicle quoted George Galvis, executive director of Communities United for Restorative Youth Justice, as saying that Mr. Gonzalez “died in the park, like George Floyd, with his face in the grass and a knee on his back.”

The Alameda Police Department released on Friday a “coroner investigator’s report” and an “autopsy report” addressing Mr. Gonzalez’s death.  Both were prepared by the Alameda County Coroner’s Bureau.  The former document is unsigned and undated; the latter was signed by Chief Forensic Pathologist Vivian S. Snyder on September 25.  (Why it took so long to make these reports public – and why it was the City rather than the County that released them – remains a mystery.  Alameda Police Chief Nishant Joshi told us Friday that “[t]he Alameda County Sheriff’s Office completed the report and APD just got it.”)

We’ve read both reports and discussed them with persons outside City government who are more familiar with the criminal‑justice system than we are.  Having done so, we find it difficult, to say the least, to square either document with the narrative that arose right after Mr. Gonzalez’s death.

The coroner investigator’s report makes findings about both the “cause” and the “manner” of death.  What’s the difference?  According to the California Court of Appeals, “The cause of death is the disease or injury that caused the person to die.  The manner of death is how it occurred.”  And the “manner of death” can be “one of only five options:  natural, accident, suicide, homicide, or undetermined.”

Here, the investigator was able easily to rule out two of the possible options, since there was no evidence that Mr. Gonzalez died of natural causes or committed suicide.  Unless the investigator wanted to punt by labeling the manner of death “undetermined,” that forced him to choose between “accident” and “homicide.”

The report did not explain why the investigator picked the latter.  In the press release accompanying the disclosure of the reports, Police Chief Joshi suggested that “homicide” was selected “[b]ecause there was a physical altercation.”  From a layperson’s perspective, this explanation makes sense:  it isn’t as if an intoxicated Mr. Gonzalez tripped and fell dead in the park with no else around.  That would sound more like an “accident.”

The description of the manner of death as “homicide,” however, offers very little guidance in determining whether a crime has been committed.  As the California jury instructions given in criminal cases state, “Homicide is the killing of one human being by another. . . .  A homicide can be lawful or unlawful.  If a person kills with a legally valid excuse or justification, the killing is lawful and he or she has not committed a crime.  If there is no legally valid excuse or justification, the killing is unlawful and, depending on the circumstances, the person is guilty of either murder or manslaughter.”

For these reasons, if you see any demand that the Alameda cops be “prosecuted for homicide,” you can dismiss the speakers as engaging in . . . loose talk – even if he and she are members of the State Bar of California.

As to “cause,” the autopsy report is quite specific:  “[T]he cause of death is the toxic effects of methamphetamine, with the physiologic stress of altercation and restraint, morbid obesity, and alcoholism contributing to the process of dying.”  (The investigator’s report is similar.  It identifies the “cause of death” as “[t]oxic effects of methamphetamine,” and lists “Physiologic stress of altercation and restraint; Morbid obesity; Alcoholism” as “Other Significant Conditions.”)

The autopsy report contains substantial evidence in support of its medical findings.

The pathologist attached a forensic laboratory report stating that a gas chromatography – mass spectrometry screening of Mr. Gonzalez’s blood showed 907 ng/ml of methamphetamine.  According to one clinical reference guide, more than 500 ng/ml constitutes a “toxic blood level” for the drug.

Similarly, Mr. Gonzalez, who was 5 feet 5 inches tall and weighed 284 pounds, had a Body Mass Index of 47.25.  Published tables confirm that such a person is considered “morbidly obese.”

In addition, the autopsy examination of Mr. Gonzalez’s heart noted cardiomegaly (an “abnormal enlargement of the heart”) with “mild four-chamber dilation.”  (Medical researchers have found a link between “morbid obesity” and heart failure.)

Finally, Mr. Gonzalez had a “history of alcoholism”; “marked hepatomegaly” (an “abnormal enlargement of the liver”) with “severe seatosis” (“fatty degeneration of the liver”); and ethanol in his blood.

The report suggests that these medical conditions, even without any involvement by the police, could have caused Mr. Gonzalez’s death:  “The methamphetamine detected in his blood combined with his enlarged and dilated heart could have together resulted in a fatal cardiac arrhythmia.”

In any event, of the primary and three secondary factors cited in the autopsy report, only one relates to the police:  “physiologic stress of altercation and restraint.”

“Physiologic stress,” of course, may result from any engagement between a citizen and the cops, even if there is no physical contact.  But the autopsy report details how the two APD officers who initially responded to the call “struggle[d]” to handcuff Mr. Gonzalez while he was standing, and then how one of them positioned (and “repositioned”) himself over Mr. Gonzalez’s upper and lower back and the other grabbed Mr. Gonzalez’s arms and legs after he was on the ground.  It also describes how a third officer who arrived on the scene “took control of” Mr. Gonzalez’s legs.

In sum, the report states that, during his “interaction” with the police, Mr. Gonzalez “was face down on the ground (prone) with his hands handcuffed behind his back, and at times the officers were applying pressure to his torso and legs with at least some of the weight of their bodies.”

These facts, however, did not lead the pathologist to alter or modify her conclusion that the “toxic effects of methamphetamine” was the cause of death, or that the meth use and enlarged heart themselves may have been responsible for it.  Instead, the report states: “The stress of the altercation and restraint combined with prone positioning in the setting of morbid obesity and recent use of methamphetamine placed further strain on Mr. Gonzalez Arenales’ heart.”

The report does not identify any significant physical harm resulting from the restraint.  “The autopsy did not demonstrate any lethal injuries,” it states.  “Broken ribs (rib fractures) and liver tear (laceration) were documented at autopsy – features that are consistent with the consequences of aggressive resuscitative efforts.”  Moreover, the autopsy examination revealed only “superficial blunt trauma,” consisting of “cutaneous abrasions and contusions,” on Mr. Gonzalez’s torso and extremities.

The absence of trauma is one distinction between this case and George Floyd’s.  But it is the conclusion that the “toxic effects of methamphetamine” was the cause of Mr. Gonzalez’s death that materially distinguishes him from Mr. Floyd.

In the Floyd case, the medical examiner ruled that the cause of death was “cardiopulmonary arrest complicating law enforcement subdual, restraint, and neck compression.”  He noted that drugs – fentanyl and methamphetamine – had been found in Mr. Floyd’s blood, but he cited them only under “other significant conditions.”  Not including these findings as part of the cause of death means the M.E. concluded that “those were there before but didn’t start the lethal sequence of events,” a board-certified pathologist consulted by the New York Times explained.  Here, the drug use played a more prominent – indeed, decisive – role in causing death.

Predictably, the opposing sides in the Gonzalez case already are interpreting the coroner’s reports in a way that favors their case.  Despite the autopsy findings, Ms. Sherwin is continuing to insist, according to NPR, that “it was the officers’ prone weight restraint, not meth, that killed” Mr. Gonzalez.  She also attacked the County forensic pathologist’s expertise:  “It’s not uncommon for a forensic pathologist to not have a very strong handle on the toxicology or the epidemiology of mass intoxication.”

Her partner, Michael Haddad, likewise rejected the coroner’s conclusion that meth use was the cause of Mr. Gonzalez’s death.  “I’m concerned that the sheriff-coroner is trying to protect the Alameda police,” he told the Chronicle.

By contrast, Alison Berry Wilkinson, the attorney for the officers, stated during an interview with KTVU that the autopsy “clearly showed” that Mr. Gonzalez died from drug toxicity.  “It was the toxic level of drugs not the actions of the officers,” she was quoted as saying.  “There’s nothing in the report that any of the techniques used by the officers were unreasonable or excessive.  They did a tremendous job under difficult circumstances.”

Ultimately, the autopsy report and the coroner investigator’s report will form only part of the record District Attorney Nancy O’Malley will consider in deciding whether to charge the three Alameda cops with a crime.  And those reports, as well as testimony from their authors, will constitute only part of the evidence presented to a civil jury (if Mr. Haddad and Ms. Sherwin follow through with their stated intent to file a suit for damages) and/or a criminal jury (if Ms. O’Malley does bring charges).

In the meantime, we hold out little hope that the coroner’s reports will prompt any modification of the narrative that the Alameda cops killed Mario Gonzalez like the Minneapolis cops killed George Floyd.  But at least now a conscientious observer will have a dispassionate source of information against which to evaluate any outlandish claims.


Autopsy reports: Coroner’s Investigative Report; Autopsy report

About Robert Sullwold

Partner, Sullwold & Hughes Specializes in investment litigation
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17 Responses to The Gonzalez autopsy reports

  1. Common Sense says:

    Sadly, his death becomes part of a “narrative” constructed by others to achieve a political goal, not “justice.” The BLM/progressive “defund the police” movement died in the aftermath of the double whammy Kyle Rittenhouse not guilty verdict and Darrell Brooks lethal actions in using his vehicle to run down grandmothers and children in the Waukesha Christmas parade, as Americans were jolted by the stark consequences of failing to enforce laws and at the same time, empty the jails.

    I doubt the Coroner’s report will be dispositive,

  2. Anon so I don't get a brick through my window says:

    Cause of death was resisting arrest with a bad heart.
    As for the behavior of the police, I went back and transcribed some relevant moments from the video. All time markers are approximate:
    First caller describes trespassing & intoxicated behavior
    Second caller describes stolen bottles & baskets
    5:40 cop asks if ok, Mario says yes
    6:15 M says “something happened over there” while gesturing toward Walgreens — to me that indicated he was forming an excuse for stolen liquor and baskets, on which Walgreens labels were clearly visible
    7:12 M says he’s not in self harm mode
    10:50 Asked where alcohol came from, M responds evasively, body language gets very nervous
    11:25 Says his name is Mario
    11:55 Mario points toward Walgreens and says they told him to never come back — is that an indication he’d shoplifted there before if not that day?
    13:10 Denies his name is Mario, then cops says “I have to identify you, make sure no warrants” Mario says “Oh shit”
    He’s very much aware he’s about to be arrested for stealing and maybe other offenses
    13:35 Officer offers an out, promise to never drink in parks and you can go. M gets even more nervous — does he perhaps have an outstanding warrant? You’d think cops would have already told the world if that was the case, but M acts like he knows he has a warrant.
    Then officer makes clear Mario must identify himself or will be arrested (used the phrase “take you in”). Mario does not comply.
    14:30 Warning about hands in pockets
    14:45 Cops begin to cuff. They move slowly and gently
    15:15 Officers politely ask him to stop resisting (first of many times) M says “I didn’t steal nothing,” continues resisting while standing
    17:30 On the ground, you know the rest
    Officers behaved professionally, moved slowly, gave Gonzales many, many opportunities to comply with lawful requests and when it came time to arrest, they were not rough or reckless. They moved slowly and escalated only because Gonzales resisted. It is highly unlikely charges will be filed and if they are, the video is significant evidence in the cops’ favor.

  3. Bootlicking says:

    “We have investigated ourselves and found no wrongdoing.” And then conservative blogs provide additional cover by overly diluting what the word “homicide” means, after burning the word 12 paragraphs down, of course.
    You’re forgetting one incontrovertible fact: Mario Gonzalez would’ve been alive today had APD not kneeled on his back for an excessively long time, against department protocol. His poor health and drug use were contributing factors, but he would have been alive had nobody called APD. Full stop.
    Not once did you mention the need to practice de-escalation or the need for police to use proper response after assessing the health and mental capacity of the person.
    It is quite alarming that anyone could provide this much justification in supporting police officers to be judge, jury, and executioner without any due process. Simply find anyone who looks to be in poor health, harangue them to provoke an arrestable response, force them into the ground for 10 minutes, and let the “contributing factors” take care of the rest. One less person off the clean streets of Alameda.

    • Anon so I don't get a brick through my window says:

      Watch the video.

      Cops were calm and even handed, gave Gonzales many chances to comply with a simple & lawful order. When they began to cuff him, they moved slowly, said “please do not resist” several times. He continued to resist.

      Gonzales died because he made a series of terrible decisions, among them: doing meth, shoplifting, and resisting arrest.

      • Bootlicking says:

        Alameda’s police policy manual is very clear: “Once secured, the person should be placed in a seated or upright position, secured with a seat belt, and SHALL NOT BE PLACED ON HIS/HER STOMACH FOR AN EXTENDED PERIOD, AS THIS COULD REDUCE THE PERSON’S ABILITY TO BREATHE.”

        The last couple minutes, Gonzalez was not resisting and was actually apologizing. Look at your original comment above, giving very detailed and subjective “transcribing” of video events that were unfavorable to Gonzalez, but once he got to “17:30 On the ground, you know the rest,” with no details, because the police did wrong – Mario started dying here. The police forced him to the ground for 5 minutes, an excessively long time and in violation of the policy manual. There’s a reason why this was ruled a homicide: it was entirely preventable by APD. Mario Gonzalez did not coincidentally die the same time he was being arrested.

        I’m reminded of the Colorado officers who shoved a 73-year-old lady with dementia to the ground because she was also being noncompliant. I suppose you’re okay with that as well? Those officers were fired because they did not assess the situation properly and take measured response based on the overally condition of the person, and the lady is receiving a $3 million settlement. Gonzalez, a man who was not in the right mental capacity and physical health – what makes him so different from the Colorado lady? He was Mexican?

      • Anon so I don't get a brick through my window says:

        Policy begins with the words “Once secured.”

        Gonzales wasn’t secured BECAUSE HE CONTINUED TO RESIST.

        The ball was in his court to comply. He chose not to.

      • Anon Bootlicking says:

        Anon: notice how you put all of the responsibility on a man who clearly did not have the mental faculty to make sound decisions, and none of the responsibility with the police officers who are trained to assess and de-escalate situations. Restrained or not, the police clearly knew the fatal danger of placing someone on their stomach for an extended period of time.

        Going back to your rather subjective transcribing of the Mario Gonzalez video: you omitted perhaps the most damning quote of the entire video – an officer could be heard shouting to another officer, “no weight on his chest!”

      • Anon so I don't get a brick through my window says:

        The “no weight on his chest” was shouted while he was actively resisting. He was not “secured” which is the word that the policy uses.

        This is a very unfortunate situation. The fault lies with Gonzales.

      • Anon Bootlicking says:

        For someone who professes to know everything that happened, you do not even have the heart to spell the man’s name correctly even once. Gonzalez.

      • Anon so I don't get a brick through my window says:

        The only things I know I learned from watching the video.

        Watch it for yourself. You’ll see that everything I have typed is in the video.

  4. Karen Bey says:

    My deepest condolences to the family for the pain and loss they’re feeling. I watched the video and was horrified watching with disbelief. I’m so sorry!

    The video shows that one officer put an elbow on his neck and a knee on his shoulder, while another appeared to put a knee on his back and leave it there for about four minutes as Gonzalez gasped for air.

    All because Mario stole some alcohol and was hanging out in a park? How many of us have kids that do stupid things?

    Mario Gonzalez did not have to die!

    • Anon so I don't get a brick through my window says:

      Hanging out with stolen alcohol isn’t what killed him. Resisting arrest while in shockingly bad health is what killed him.

      The reason the officers had an elbow on his neck and a knee on his back is that he continued to resist. He was fighting for several minutes, from the time they began to peacefully and calmly apply handcuffs at about 14:45 up until after the 22:00 mark.

      Watch the video.

      • Just The Facts says:

        I’d be “fighting for several minutes” if my life were in mortal danger, having my back and neck kneed while being asphyxiated and while having my arms stretched back across my overweight body. Most viewers who watched the video seem to disagree with you. This made national news for several days and a state bill was passed. Are you a subject matter expert on arrests? Or did you watch a different video?

      • Anon so I don't get a brick through my window says:

        Do you not realize that the “mortal danger” was because Gonzalez refused to comply & chose to resist?
        The cop tells him straight up that if he identifies himself & promises not to drink in Alameda parks again, he can walk away free. He refused. When the cops began to calmly & gently cuff him, he fought. The “mortal danger” was entirely his own making. The knees happened because he resisted arrest.

        These comments really make me wonder if you watched the video.

  5. Just The Facts says:

    I recommend that people look up the California Assembly Bill 490, recently passed in September to hopefully prevent another Mario Gonzalez tragedy. The law bans officers from placing individuals into a prone position that could lead to positional asphyxia. If the officers truly did no wrong, ask yourselves whether they would have been in violation of AB 490 today. I agree with Karen Bey’s accounting of the video – it is shocking that anyone else could have purported to watch the video (looking at you, Anon) and not notice that officers were kneeling Mr. Gonzalez’s back for 4-5 minutes.

    • Anon so I don’t get a brick through my window says:

      I agreed upthread that cops had knees on him. In the video that I watched, they did so because Gonzales continued resisting arrest.

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