A 54-year-old Palo Alto woman sat hunched over on the ground outside her home in early June, pleading repeatedly with police officers to get her medical help.
As one officer peppered her with questions, including whether she had been drinking or was on medication, she became more and more desperate, fearing she was suffering a potential deadly stroke.
"I've got to go," she told police, who were standing over her. "I've got to go. I've got to go right now. I don't think I have a lot of time left. There's something really wrong."
The crews of a fire engine and a paramedic unit were on hand and ready to treat her, having arrived within just five minutes of the 911 call. But the city of Palo Alto dispatcher ordered them to remain out of sight a block away, where they waited eight-and-a-half minutes until police arrived and then another five minutes before police allowed them in.
It was one of many actions by the police during the incident that violated city policy, including an unexplained five minute stop by the responding officer three blocks from the woman's house, the absence of body-worn camera footage of a police sergeant, missing GPS data for the sergeant's patrol car, a search of the woman's house and the sharing of confidential information about the incident by a police officer with her spouse, who then conveyed it to others.
For more than two months, the Weekly as well as the woman and her husband have sought answers from the city about the handling of the incident. City staff initially refused to disclose any information, forcing the family to engage an attorney for help. Eventually, the city provided some, but not all, time-stamped police audio and body-worn camera video, fire dispatch tapes and logs, recordings of the 911 call and fire department reports.
The Weekly also sought interviews with city staff, who initially agreed only to answer written questions. When pressed for in-person interviews, City Manager Ed Shikada agreed to make himself and Police Chief Bob Jonsen available. But he then changed his mind and said no one at the city would answer any questions pertaining to the incident, in writing or in person. He gave no explanation for the refusal and instead only issued an eight-paragraph statement. (Read more in "A tug of war.")
The woman and her husband provided the recordings they'd obtained to the Palo Alto Weekly, saying they were concerned that what happened to her could lead to tragic consequences for others if the police department's violations of protocol and lack of effective training are not corrected.
'I was starting to disintegrate as a person'
The petite Palo Alto resident, whose identity the Weekly is withholding to protect her privacy, started experiencing strange neurological symptoms similar to a stroke around noon on June 3. She began seeing double vertically, was dizzy and felt increasingly disoriented. She had a sense of losing awareness of one part of her body, she said.
Too impaired and confused to find her phone and call 911, she went out to her front yard to seek help from neighbor children she heard playing basketball.
"I thought: 'If I lay down on this bed I'm going to die. I need to go outside. If I collapse on the street, someone will find me,'" she told the Weekly during an interview in July. "I ran. I just ran toward the noise. I was starting to forget who I was. I was losing my awareness of who I was, where I was. I was starting to disintegrate as a person."
She encountered a 10-year-old neighbor boy and, stuttering, she struggled to ask for help.
"I had great difficulty. I remember getting really scared. I said, 'Please call 911. I need medical attention or I'm going to die. If I don't get medical attention, I'm going to die.' I said this several times," she recalled.
The boy, his older brother and their father tried to comfort her. The father stayed with her as the 14-year-old boy called 911 on a cellphone.
But the response the woman got from the city was anything but the life-saving help she expected.
The dispatcher who answered the 14-year-old's 911 call, Brina Elmore, immediately dispatched fire units to the scene, but within 60 seconds, she ordered those responders to hold up around the corner from the victim and "stage" until police arrived.
Moments later a second police dispatcher initiated the lowest possible non-emergency police response, stating that it "sounds like it's going to be more 5150 than medical," indicating dispatchers had concluded that they were dealing with a psychiatric problem rather than a medical emergency.
The sudden change in response came because of a single statement made by the 14-year-old, prompted by Elmore asking him to assess the woman's medical condition within the first two minutes of the 911 call.
After obtaining the address from the eighth-grader and dispatching paramedics, Elmore asked, "Do you think it's a medical issue or is she having some type of psychological issue?" according to recordings.
Taken aback, the boy said, "I don't — it seems psychological to me, but I am not the one to make a decision on that." He told Elmore that the woman was repeatedly asking for medical assistance and saying that she was going to die. At the dispatcher's prompting, he said the woman had no weapons and confirmed that the woman was not behaving as she normally did.
Elmore's decision to characterize the call as a non-emergency psychiatric call, heard via radio by responding police and medical units, not only set in motion a delay in medical help but shaped how both police and fire personnel approached the urgency and severity of the incident.
In the end, the woman waited for over a half hour before finally being loaded into the ambulance. En route to Stanford Hospital, paramedics realized that her medical emergency was actually a seizure, which had begun around noon and became more severe in the ambulance, according to the woman. It developed into a grand mal seizure upon arriving in the emergency room, 42 minutes after the 911 call. After tests were done, she was diagnosed with a brain tumor and has since undergone brain surgery.
Staging gone wrong
The handling of the 911 call has raised questions about how a policy that prioritizes paramedics' rapid access to patients morphed into an unwritten practice that put police in charge of making medical diagnoses when a patient exhibits possible psychiatric symptoms — and about the urgency, or lack thereof, attached to those calls.
Police Officer Yolanda Franco-Clausen, who was dispatched a minute after the fire department was, traveled without lights or siren from less than a mile away and arrived at a point three blocks from the woman within six minutes, according to police GPS tracking data. For a still-unexplained reason and without informing the dispatcher, she then stopped for five minutes two blocks away from the waiting fire personnel and less than a 30-second drive from the woman's location, according to the GPS data.
It took Clausen 11 minutes to get to the address. Her supervisor, Sgt. Adrienne Moore, met up with Clausen there and made a point of reminding her to turn on her body-worn camera as she got out of her patrol car. According to the city, Moore's vehicle and body cam footage does not exist, but it has not explained why.
Clausen's body cam video chronicled what happened next: The two officers approached the woman, who was sitting on the ground with her neighbor, who had his hand on her knee. His two boys stood nearby. Despite it being obvious that the woman posed no danger to firefighters that required any further delay in getting her medical assistance, Clausen instead proceeded to try and determine what might be wrong with her, talking with her for five minutes.
The video shows the woman exhibiting a neurological condition known as aphasia, in which a person uses partial and nonsensical words. Aphasia is a symptom of some strokes, head injuries and brain tumors, according to the American Stroke Association. The city's own protocols describe aphasia as an indication of a possible stroke.
"What's happening to me is — I have some kind of a serious — helpl — uh, help. I have a serious — serious — OK. I — I'm gonna lose my ability to — to make a — Please take me to ...," the woman said, according to Clausen's body-camera footage.
At this point, Clausen told the woman, "We have an ambulance on the way right now. ... I just have to ask you a few questions. Do you feel like harming yourself today?"
"What? No. I have some kind of serious — help! I need help!" the woman said.
"I'm trying to understand what kind of help we need today. Are you injured?" Clausen said.
The woman put her hands to her face as she struggled for the words.
"Um, please take me to — helpital, uh, uh," she said.
"Do you want to go to the hospital or do you want to see a psychiatrist?" Clausen asked.
"No no no no no no no. Oh my god," the woman said.
"What do you need? Tell me what you need," Clausen said as the woman became more panicked and struggled for words.
"Here is what I need. I need — I need — I need helple."
"Have you had anything to drink today?" Clausen replied.
As the exchange continued, the fire captain, who had walked down the street and joined the officers, radioed for the paramedic and fire crews to come to the scene.
When police make medical decisions
The gaffes made during this emergency raise questions about why the police failed to follow city protocols or if they were unaware of those rules.
The city's staging policy is specific. Staging is required for all incidents involving violence. Violent incidents are defined as "shootings, stabbings, assaults, or any other type of incident in which fire department personnel may be exposed to harm as a result of a violent act."
For incidents in which the city's emergency dispatch center staff know or suspect that violence has been involved, or the potential exists, the call will be dispatched with instructions to "Proceed with caution."
For calls in which the dispatcher knows or suspects that the potential for further violence exists, such as a sniper, fight in progress or violent perpetrator in the area, the call will be dispatched with instructions to "stage and await P.D. arrival."
The woman did not exhibit any of the traits required for staging under the city's policy. The boy told the dispatcher the woman was not armed. She had not displayed any tendency toward violence and the boyexpressed no fear of harm or violence. Still, the dispatcher noted in the computer log, "Neighbor came over and she's stuttering and he's not sure it's a psychological issue or not." Later in the log, the dispatcher said the boy had informed her the woman "seems psychological not medical but he isn't sure." The woman didn't have any weapons, the dispatcher informed the fire department.
In a July 8 meeting with the woman's husband, Jonsen expressed concern for how the dispatcher handled the call, according to the husband. Jonsen said the conditions under which fire personnel are staged has "drifted" from the policy over time to include situations where there is a psychological factor. Jonsen told the husband he is changing the policy to explicitly require officers to show up faster and to quickly assess whether the person poses a threat, and if not, to get out of the way so that medical first responders can tend to the person.
The actual procedures employed during the woman's medical crisis evolved due to the 2015 Christmas Day fatal police shooting of William Raff, a psychiatric patient who ran toward police with a table knife after he made a 911 call about an alleged threatening person at a residence, Jonsen told the woman's husband. (As with other city staff, Jonsen declined to answer questions from the Weekly.)
But expecting police officers to make medical assessments, especially recognizing the signs of a serious neurological condition, has been problematic for the city in the past. In April 2014, 63-year old Palo Alto resident William Bedwell suffered a hemorrhagic stroke while driving on El Camino Real to his job as a research scientist at SRI International. He struck three cars and kept going. When police arrived, he had trouble keeping his balance, appeared disoriented and bumped into an officer. Instead of summoning paramedics to evaluate the man, police officers cited him for hit-and-run and a tow-truck driver took him to work. When he arrived at SRI, co-workers called paramedics, who transported him to Stanford Hospital. He died three days later after surgery for severe brain injury.
Bedwell's sister, a doctor, wrote a letter to the City Council, then-Police Chief Dennis Burns and other city leaders raising an alarm over how police handled the incident.
"I am appalled that this could happen in your community," she wrote.
Bedwell's wife told the Weekly at the time, "It's not about wanting to get anything out of this. We feel what happened was unacceptable, and we don't want this to happen to anyone else."
Shikada, in response to the June 3 incident, issued a statement saying that additional training had been provided to dispatchers and that the city has "clarified" and "reinforced" policies regarding dispatching police to medical emergencies and staging protocols.
In a follow-up email, he said the city's policy for handling psychiatric-related calls, as the June 3 incident was erroneously determined to be, requires the police officer to "quickly evaluate if medical attention is needed and request medical support as soon as it is safe to do so."
The city's staging policy, however, makes scant mention of police responsibility to evaluate the need for medical attention. The Palo Alto Police Department policy manual does not specifically give police the discretion to make medical diagnoses.
The city's unwillingness to answer questions has made it impossible to reconcile the apparent contradictions or clarify how a similar incident will be handled in the future.
Shikada's statement concluded: "We deeply sympathize with the individuals involved and their family, recognizing the difficulty of the circumstances involved. We understand the concerns raised with the handling of this call and would like to express our appreciation for bringing these issues to our attention."
But the woman involved in the June 3 incident said that such reassurances are meaningless without accountability.
"If the police and fire departments had followed existing policy, this wouldn't have happened. The fact that seemingly no one is being held accountable for failing to follow policy means it's likely to happen again. Our City Council should hold the city staff accountable before someone else suffers potentially fatal consequences," she said.
Illegal searching and other problems
Additional concerns have arisen in the June 3 incident about invasion of privacy, illegal searching and the use of body-worn cameras.
When paramedics finally began attending to the woman, Clausen conversed with the woman's husband, whom the neighbor had reached at work on his cellphone. Clausen asked if she could peek into the home.
"I just want to verify with you, if the door is unlocked can I just see if anything is lying on the floor or anything in the immediate location in the front there?" she said, according to the body cam video.
The husband agreed. But while still talking with him, Clausen entered the home and searched the woman's knitting basket, which was sitting on a foyer table. Without telling the husband, she proceeded to walk farther into the home through the dining room, kitchen and breakfast nook. She searched the woman's purse, then peeked into what appeared to be a study or a bedroom. On her way out, she checked a parcel underneath the foyer table.
Clausen can be heard telling the husband that she hadn't found any drugs or alcohol or any sign of what might account for the woman's disorientation. However, neither the husband nor the woman were aware of the extensive search until they obtained the body cam video recording weeks later from the city, they told the Weekly.
In addition to Clausen's search of the woman's residence beyond what the husband had authorized, Moore appears to have violated department policy, adopted in 2018, when the body-worn cameras were first deployed, requiring officers to verify that both the in-car video system and body cams are operational at the beginning of their shifts and to report any problems immediately. During the incident, she should have activated her body cam; the car video cameras are supposed to automatically activate. The recordings are also supposed to be automatically downloaded and preserved under specific procedures, and they cannot be altered or deleted, according to policy.
Finally, in another wrinkle that raises additional questions about police conduct, the Weekly obtained copies of text messages sent by Clausen's spouse, Shay, that conveyed confidential information about the incident to an acquaintance, another violation of department policy.
Shay and a woman were texting when the woman commented about the Palo Alto resident having had a medical crisis. Shay then volunteered that Clausen had been at the scene and that "It wasn't true."
In a later text to the same person, Shay stated the Palo Alto resident "is not telling the truth, that's all I can say." She also accused the resident of filing a complaint against Clausen, which the resident later said she had not.
Preventing future tragedies
All of these questions continue to nag at the woman, who said she wants reform so that similar incidents won't endanger other Palo Alto residents who call for help in a medical crisis, especially a neurological one for which delayed treatment has severe consequences.
"It was excruciating for the 20 minutes I waited for help," she said during the July interview.
"I'm a middle-aged woman in pajamas and slippers sitting in the dirt in the street. I had no weapon of any kind and wasn't acting threatening to myself or anyone else, nor was I intoxicated, and my neighbor confirmed that to the dispatcher before the first responders arrived," she said. She noted that she is a teetotaler and hasn't drank alcohol of any kind for more than 30 years.
If police really suspected she was somehow dangerous, it would have made sense to move people away from her or clear the area for her privacy, she said.
"The wrong people came. ... Even after I was in the ambulance and on my way to the hospital, the police were still insisting to my neighbors that my illness wasn't 'physical' but 'just some sort of episode.'"
The woman, who has a background as a wilderness first responder, said she was struck by the fire department incident commander's ineffectiveness during the exchange with police.
He "is standing nearby watching me struggle and not taking command of the scene as incident commander but is allowing police to continue to try to 5150 me (the term for putting a patient on a 72-hour psychiatric hold). No one has yet checked my level of orientation (name, place, date, situation), asked whether I have bumped my head, fell, take insulin, have epilepsy, eaten anything I might be allergic to — nothing.
"No one has done a FAST check (stroke-determination criteria), even though I was having trouble speaking," she said.
The long lag caused by the police delayed the diagnostic scans she needed and the delivery of needed anti-seizure medication, she said.
"I was pleading for help and I didn't get it. I was incredibly scared and at one point said to my neighbor: 'I'm going to die today.'
"I had done the right thing. I had got myself outside. I had got myself to humans. I had asked for medical help and 911 was called. But when they came, they didn't help me. If I had actually been having a stroke, I could have been dead.
"This is just a botched response from minute to minute. ... The city's response showed no respect for my dignity or privacy as a patient," she said.
Stacey Leyton, an attorney with Altshuler Berzon LLP who is representing the woman, said in an email that her client has not thus far filed a complaint with the city or a lawsuit.
"My client was deprived of emergency medical attention that she desperately needed and had every right to expect," Leyton wrote. "In seeking an explanation for the police response, my client exercised her right under California's public records laws to obtain from the city documents and video that should have been readily available to her. It should not have required a lawyer's involvement for her to obtain access, but it did.
"We have obtained information from the city that sheds some light on the incident, but critical information is still missing from the city's response. The city has not provided any explanation thus far for these gaps in information.
"This (medical) delay had serious emotional and physical consequences and could have been life threatening. No individual who calls for emergency assistance should have to worry that help will be withheld in this manner," Leyton wrote.