The NBC Bay Area Investigative Unit’s probe of the deaths of two suspects — who died separately in San Francisco after being given a common sedative to control them — has led to a state investigation.
The state’s Office of Emergency Medical Services is probing whether paramedics who administered the sedative Midazolam broke protocol that required them to engage constant electronic monitoring.
David Monroe says his stepson, Carlos Margo, was just 36 when he died back in March of 2017 after being arrested by police.
Records reviewed by NBC Bay Area show officers had come to a bar in the city’s Castro District and tried to arrest Margo, who resisted.
But records and photos show Margo was restrained and on a gurney when a city paramedic injected him with a 5 milligram dose of the common sedative, which slows breathing.
After getting a call about Margo being in the hospital, family rushed to be at his side. “When we got there I could tell he was already gone – there was no brain activity or anything,” Monroe said. “There were at times 70 people at the hospital praying for him.”
Margo died 13 days later of anoxic brain injury – which is triggered by oxygen deprivation. Monroe says that while he may never know if Midazolam caused that condition, there was never a need to sedate him in the first place.
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“When they injected him, he was handcuffed,” Monroe told NBC Bay Area, “and they had a bunch of guys holding him down on the ground. I mean, why’d they have to do that after he was already handcuffed?”
Back in 2015, another suspect died after being injected with Midazolam. He too had clashed with police who took him to the Hall of Justice on an outstanding traffic warrant. Darnell Benson was just 40 when he died of the same kind of injury to his brain, which is a known complication from Midazolam.
Both deaths, however, were ultimately blamed on methamphetamine.
But records show in both cases, medics did not monitor the men’s vital signs electronically before and after injecting them with the sedative, which is given to calm between 1,000 to 2,000 suspects every year in the city.
Such monitoring is required under city protocols to guard against breathing and heart-related complications known to be linked to Midazolam. While the autopsy originally found that Midazolam played a role along with methamphetamine in Margo’s death, the final conclusion was changed to death from methamphetamine overdose “while under law enforcement restraint.”
San Francisco public health officials, meanwhile, said they “did a comprehensive investigation of both cases and there were no adverse findings. The cases were closed.”
But after our initial report on the deaths, officials with the state Office of Emergency Medical Services confirmed that it had led them to start a still ongoing investigation into whether the medics followed required treatment protocols.
“Good, at least somebody’s looking into it,” Monroe said, adding that while it is too late to save his stepson, he hopes the probe will prevent someone else from dying under the same circumstances.
“Why’d they have to inject him with that stuff? There’s something wrong.”
