Jan. 23, 2023 Officials determined the restraints Chicago Paramedic Dakota Ibrahim placed on the man contributed to his death.
By Jake Sheridan, Jeremy Gorner Source Chicago Tribune (TNS) Distributed by Tribune Content Agency, LLC.
The Chicago Fire Department has fired a paramedic after an internal affairs investigation into the death of a Buena Park man determined the first responder did not attend to the patient and then allegedly submitted a false report after the patient’s death.
Leonardo Guerrero, 44, was pronounced dead at Thorek Memorial Hospital in Uptown on Aug. 31, after he stopped breathing while strapped to a stretcher in an ambulance. Restraints applied by paramedics to Guerrero contributed to his cardiac arrest death, which was also affected by high blood pressure and primarily caused by cocaine and alcohol use, the Cook County medical examiner’s office said. The office ruled the death a homicide.
Following the internal affairs investigation into his death, the Fire Department on Nov. 20 fired Dakota Ibrahim, the paramedic in charge of Guerrero’s care. His fellow responding paramedic, Joseph Schultz, has been suspended from the Fire Department.
Both paramedics’ state licenses were also suspended by the Illinois Department of Public Health, six months for Ibrahim and three months for Schultz. They will be able to work as paramedics in Illinois after completing their suspensions.
Guerrero’s loved ones told the Tribune on Thursday night that they were surprised to learn the circumstances of his death after having “no idea” what had happened, and they called for harsher punishments beyond the suspensions given to the involved paramedics.
“You can’t believe it happened, and then you go into anger, and then you go into being hurt because you will never see your brother again,” his sister Sylvia Guerrero Tanguma said.
Ibrahim’s attorney, Patrick Walsh, disputed parts of the Fire Department’s characterization of what happened and said the 30-year-old paramedic should be allowed to work again.
“There was nothing that Dakota did or did not do that caused Mr. Guerrero’s death,” Walsh said.
The news of the firing, uncovered by a series of Tribune information requests, comes days after two Sangamon County paramedics were charged with first-degree murder in the death of a patient. That patient, 35-year-old Earl Moore of Springfield, died of asphyxia after being strapped face down to a stretcher, the autopsy report said. Under Illinois law, a first-degree murder charge can be filed when a defendant “knows that such acts create a strong probability of death or great bodily harm.”
In Guerrero’s case, no criminal charges have been filed against either of the paramedics who transported him, and police were unable to share any details because it is an open death investigation. Cook County State’s Attorney Kim Foxx’s office said it did not have any information to share regarding his death.
According to police and Fire Department records, police called for paramedics on Aug. 31 after discovering Guerrero lying naked in a parking lot near his home in the Buena Park neighborhood. He appeared to be on drugs and hallucinating, officers wrote in a police report. Guerrero tested positive for cocaine and alcohol during his autopsy.
Guerrero told police he was dying and that he didn’t want to die, and he “could be clearly seen as suffering from some form of respiratory crisis,” according to the Fire Department’s internal affairs report.
The paramedics’ missteps started when they got out of their ambulance with no equipment, the report says. The breakdown in protocol continued from there, according to the findings.
Police body camera footage reviewed by investigators shows Ibrahim and Schultz conducted no preliminary assessment of Guerrero upon arriving, despite his apparent medical crisis, the report said. The paramedics then asked Guerrero, who was nude, to walk 50 feet to the ambulance, and he got up and followed the command.
After getting in the ambulance, Guerrero was reluctant to lie down and tried to leave, the report says. The paramedics then secured him to a stretcher, and police handcuffed him to it.
As Schultz drove the ambulance to nearby Thorek Memorial Hospital, Ibrahim sat by Guerrero’s head, with a police officer also sitting in view of Guerrero. The body camera footage shows Guerrero “was lapsing in and out of consciousness” and gasping for air during the three-minute ride.
As Guerrero’s breathing slowed, Ibrahim chatted with the police officer and talked about his day, according to the report.
“Ibrahim did not assess or care for the patient at all,” the report said.
Schultz noticed that the previously agitated patient did not appear to be moving and seemed calm when the ambulance arrived at the hospital’s emergency room bay, he told investigators. Schultz said he asked Ibrahim if the man was still alive. Ibrahim replied that he was, Schultz told investigators.
Ibrahim then told Schultz to alert emergency room personnel that they had arrived, according to the report. As Schultz waited to speak with a nurse on the phone in the hospital, Ibrahim took around five minutes to fill in paperwork, still making no attempt to assess or communicate with Guerrero, according to the report.
“The patient was simply left unmonitored, unassessed and untreated,” the report said.
When a police officer pointed out that Guerrero appeared to no longer be breathing, Ibrahim checked his pulse for the first time and loosened the restraints, the report said. They were just feet away from the emergency room. Body camera footage shows Ibrahim telling police to “shut the door” of the ambulance, the report said.
Ibrahim performed CPR in the ambulance before Guerrero was brought into the emergency room, where he was pronounced dead.
The medical examiner’s office determined that cocaine and ethanol (or alcohol) toxicity, high blood pressure and “stress complicating restraint” caused Guerrero’s death. The office determined the death was a homicide, noting it occurred partly because of “a volitional, potentially harmful act of another,” but adding that the ruling does not mean anyone intended to cause fatal injury.
The restraint and the use of drugs and alcohol “are intertwined,” the autopsy says. “It is not possible to separate out the extent that each played in his death, nor to say with certainty if his death would have occurred with only one or the other.”
Body camera footage shows Ibrahim telling emergency room personnel Guerrero “just coded right as we pulled in” as he was moved inside the hospital, the report says. The claim was “clearly a false statement,” it adds.
Fire Department protocol requires paramedics to notify hospitals before ambulances arrive. Ibrahim wrote in a patient care report he had unsuccessfully called the hospital three times. But body camera footage shows no evidence of Ibrahim calling the hospital and captures him telling Schultz he had not called, the report said.
Ibrahim had to say in the report that he called the hospital three times because the Fire Department’s software did not have an option for “did not call,” Walsh, his attorney, said. Fire Department spokesperson Larry Langford confirmed the department’s software previously did not allow paramedics to say in their reports that they hadn’t called the hospital. He said the software has since been changed.
In Ibrahim’s patient report, he indicated that he had been unable to test Guerrero’s vital signs “due to safety concerns for crew and officers,” but said he was able to complete a basic impaired consciousness examination that involves visual and physical assessment. The investigation notes he never tried to physically assess Guerrero before the man stopped breathing.
The paramedic described Guerrero as “combative” in the patient report, a word officers also used in police reports, and Ibrahim told investigators Guerrero’s demeanor prevented immediate definitive care. Ibrahim’s patient report also describes Guerrero as not injured, despite the body camera footage showing him bleeding from abrasions on both knees.
“Ibrahim’s notes were at best inaccurate and at worst wholly falsified,” the internal affairs report says. Schultz also signed the patient report.
While body camera footage shows an agitated Guerrero not following an initial command to lie down in the ambulance, it also shows that “at no time did (he) become combative,” according to the internal affairs report.
Ibrahim told investigators he had visually assessed Guerrero and determined it was best to transport him quickly to the emergency room instead of providing immediate care. He also said he closed the ambulance doors upon realizing Guerrero wasn’t breathing “because he wanted to protect the patient’s privacy,” the report said.
Ibrahim received a six-month suspension from the Illinois Department of Public Health, meaning he will be licensed to work as a paramedic in Illinois in late April. Schultz’s state paramedic license was suspended for three months, an IDPH spokesperson said.
The suspensions are too short, Guerrero’s family said.
“These people should never be allowed to work in a field like that again,” sister Veronica Guerrero said. Paramedic training should be reformed, his family said.
Guerrero’s family has tried to obtain more information about his death, even flying to Chicago from Texas the day after he died, but had not been made aware that the Fire Department completed its investigation until speaking with the Tribune.
Guerrero’s mother and four of his five sisters, all of whom live in Texas, and his best friend and roommate, Phillip Liming, said they were not aware of the details surrounding his death. The family hired a lawyer and is considering legal action.
His loved ones remember Guerrero as a peacemaking “teddy bear.” The sometimes shy, big bartender had an infectious laugh, played with his nieces and nephews like a “big child,” and was quick to tell others he loved them, they said.
The Fire Department’s description of the medical care Guerrero received before dying made them feel angry and hurt, they said. The loved ones believe paramedics wrote Guerrero off when they first saw him as a naked, intoxicated Hispanic man.
“They just saw a homeless person in their eyes. They saw no value,” Guerrero Tanguma said.
Their brother had a strong fear of doctors, and 911 calls show he had been shouting out for help before police arrived, Guerrero’s sisters said. Guerrero was not a “combative” person, they reiterated, and it must have been scary and humiliating for him to be suffering a medical emergency and be asked to walk naked to the ambulance, they added.
“It hurts us to know he suffered,” Guerrero Tanguma said.
Walsh said Guerrero’s death should not cause the end of Ibrahim’s paramedic career. Ibrahim “is an exceptional young man who chose a life of service to the people of Chicago” and “could be a valuable resource to any community he serves,” Walsh said.
Walsh said Ibrahim was in the best position to see Guerrero’s condition while the man was being transported and he did not see any signs that he had coded before the ambulance arrived at the hospital. Ibrahim also never intended to submit false reports, he added.
Ibrahim made $79,217 while working for the CFD in 2020 after he was hired in early March of that year, according to the Illinois Answers Project.
Despite choosing to fire Ibrahim and suspend Schultz, fire officials did not immediately disclose for how long they suspended Schultz. Through a Fire Department spokesperson, Schultz declined to comment. The department cited “the less egregious nature of his actions” and his status as a newly hired candidate fire paramedic as reasons for the lighter discipline given to him.
“The core mission of the Chicago Fire Department is to save lives and protect property. The actions of these paramedics, in totality, did not adhere to our policies and procedures to do all we can to provide the best medical care on the scene and en route to the appropriate medical emergency department,” Langford said.
Coming to the paramedics’ defense, the Local 2 Chicago Firefighters Union described Guerrero’s death as a tragedy and the body camera footage as “heart-rending,” but added that it does not tell the full story.
Ibrahim and Schultz were on their 19th run of their shift, which came as the crew had been working 24-hours-on, 24-hours-off for months, the union said. Local 2 plans to arbitrate for Ibrahim to regain his job “because of the strain which he was under and other extenuating circumstances” and called on the city to provide citizens with “enough ambulances and first responders.”
Tribune reporter Rosemary Sobol contributed.