A new analysis by Palo Alto's independent police auditor, Office of Independent Review (OIR) Group, of an investigation into how a 911 call in June 2019 was handled has found that first responders made mistakes but that their decisions were for the most part "reasonable" for the situation.

The Palo Alto woman who was the subject of the 911 call, however — whom police kept from receiving urgently needed medical attention for 14 minutes — is calling the findings a "whitewash."

The analysis was one of 17 in a larger auditor's report on complaint investigations that were completed between July 2020 and November 2021. OIR, a contractor of the city, provides secondary reviews of department investigations of police operations and personnel.

In this case, the OIR reviewed the findings of a contracted investigator who had been hired by the Palo Alto Police Department. The outside investigator was called in due to the number of entities involved in the case, the report noted.

While OIR agreed overall with the investigator's conclusions that the officers involved had been "reasonable" in their decisions and actions, the OIR report disagreed with some of the findings, including that there was "insufficient evidence" to establish that an officer violated policy by not wearing her body camera. The report also stated that the department should consider a more detailed policy when it comes to officers sharing with their spouses the details of a person's medical condition.

The incident caused policy changes that seek to make the response to medical events more timely, the report noted.

Errors at the dispatch level

The OIR report agreed that a Palo Alto police dispatcher had made procedural errors that caused a slowdown of the response to the woman during the June 3, 2019 emergency.

The biggest error concerned dispatcher Brina Elmore, who deviated from protocol by asking the 911 caller a "freelance" question about the woman's condition. Elmore had asked the 14-year-old neighbor who had called 911 for his opinion about whether he thought the woman could be having a mental health crisis.

In the 911 transcript released by police, Elmore had asked, "Do you think it's a medical issue or is she having some type of psychological issue?"

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."

The woman was repeatedly asking for medical assistance and saying that she was going to die, he noted.

At Elmore's prompting, he confirmed that the woman was not behaving as she normally did. He also said the woman had no weapons, nor did she give any indication she was about to harm herself or others.

Elmore failed to return to the standardized checklist of questions she was supposed to ask, which might have better clarified the situation, the OIR report found.

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," giving the code for a psychiatric problem.

Elmore's decision to "stage" the medical response team at a distance until police arrived to assess the scene's safety was based on an ambiguous response from the 14-year-old regarding the woman's mental health. It led to a slowdown in the medical response, the OIR report noted.

"At the same time, the choice to involve the police and initially 'stage' the Fire Department for safety reasons was found to be reasonable based on the dispatcher's developing sense of the call — even though the foundation for that sense was at least partially flawed," the OIR wrote.

Mixed findings regarding officers' actions

The actions of Officer Yolanda Franco-Clausen and Sgt. Adrienne Moore were largely found to have been "reasonable" and not in violation of department policies, the OIR report concluded, with caveats.

Franco-Clausen stopped three blocks away from the address and waited five minutes before meeting up with and proceeding to the scene with Moore. That was in keeping with Moore's direction, which is based on standard officer safety protocols within certain contexts, the report noted.

Body camera footage from Franco-Clausen, upon arrival at the address, showed the woman was unarmed, sitting on the ground and had her neighbor sitting beside her. His two boys stood nearby.

Although it was clear she wasn't a danger, Franco-Clausen and Moore kept the paramedics away for another five minutes while they peppered the woman with questions to try to determine what she needed. The woman, who exhibited symptoms of aphasia, a neurological condition in which a person uses partial and nonsensical words, could only respond that she needed help. The city's own protocols describe aphasia as an indication of a possible stroke.

The woman pleaded with the officers to take her to the hospital. Instead, Franco-Clausen continued a line of questioning about whether the woman felt like hurting herself, if she needed a psychiatrist or if she had been drinking.

The OIR agreed with the city's contracted investigator that Franco-Clausen's interactions with the woman seemed well-intentioned, appropriate to the circumstances, and of limited duration.

Franco-Clausen also acted reasonably when she searched part of the woman's home and her belongings without a warrant, the investigator and the OIR concluded.

"Similarly, her search of the woman's home (which was recorded in full on the officer's body-worn camera and which was authorized on a phone call with the woman's husband) seems to have been undertaken in a good faith effort to gain insight into the woman's condition," the report said.

"Overall, these outcomes seemed reasonable from our assessment of the investigation," they wrote.

OIR disagrees with some of the investigator's conclusions

The OIR report, however, strongly disagreed with the investigator's conclusions about Moore's failure to wear and activate her body-worn camera. Moore had "inadvertently" left her body-worn camera in its charging cradle within the police car, according to the report. By the time she realized her error, she thought it was a higher priority to get to the woman than returning to her car for the camera, she told the investigator.

Because Franco-Clausen was wearing and had activated her camera, the contracted investigator determined that key events of the incident were being recorded and that Moore's return to the car to retrieve her camera would not have been "reasonable."

Palo Alto police policy requires officers to make all "reasonable" efforts to activate their camera system when responding to calls for service, the investigator had stated.

"This is perhaps the least convincing of the investigator's conclusions," the OIR report noted. "The supervisor's mistake in forgetting the camera initially may well have been an innocent one, and the decision to forego retrieval of it made sense as well. But it was a mistake, and it compromised the totality of the available evidence in a call that became the subject of some controversy.

"Moreover, (Moore's) identity as a supervisor raises expectations and makes accountability even more appropriate. In our view, a better approach would have been to acknowledge the lapse as a violation and consider mitigating factors as needed with regard to any consequence."

Moore retired from the department after 24 years as a dispatcher and an officer in October 2021.

Weighing in on another controversial aspect of the case, OIR also looked at the department's policy about personnel sharing a patient's medical information. Franco-Clausen acknowledged talking about the service call with her wife — "specifically and limited to the identity of the woman and the fact she had been transported to the hospital," the investigation found.

The Police Department's contracted investigator found that these details were not of a type or nature that Palo Alto police confidentiality restrictions forbid, but the OIR report didn't entirely agree with the investigator's conclusions.

"Though the investigator's analysis makes sense in the context of the case and existing policy, the situation and its aftermath raise the question of whether further consideration (or guidance) regarding disclosure of sensitive information is warranted," the OIR report noted.

Criticisms of the OIR report

The woman, who was eventually taken to the hospital and found to have a brain tumor, has sharp words about the OIR report. She said that OIR never contacted her, her husband or other witnesses for any interviews before reaching its conclusions, which largely absolved the officers of wrongdoing.

In an email this week, she said she and her husband had spoken with Michael Gennaco, head of the OIR, in the weeks after the incident. She wasn't made aware of the investigation and had not been contacted regarding its findings. She only learned of its contents after receiving a copy from a reporter.

After reading the report, she offered the following statement: "I was subjected to a shocking lack of professional care by our police and fire departments and could easily have died as a result. I didn't even know about this 'investigation' and was not interviewed, nor were other witnesses. The result is a whitewash.

"No one has been held accountable for what happened to me, making this kind of situation likely to happen to someone else in the future. I still have nightmares about this episode, and reading this gaslighting report was retraumatizing."

Her husband also responded by email: "Readers interested in what actually happened should refer back to the Weekly's story. The city report omits critical facts and misstates others. Among the many facts omitted from the report is that failing to provide urgently needed medical care to my wife, who was having a seizure, violated city policy at the time.

"There was never any indication that she posed any risk to anyone. In my opinion, my wife was a victim of poor training and leadership by the police and fire chiefs and the city manager, and a City Council that defers to senior staff members rather than exercising actual oversight. I don't expect performance on the ground to improve until those facts change."

An occasion for change?

But the OIR report concluded that the department has made concrete changes as a result of this case.

The incident "proved to be an occasion for a thorough revisiting of related policies and practices. This systemic review resulted in concrete operational changes," the OIR report concluded. The changes included updates that "refined expectations for the timelier delivery of medical aid in situations where the police and fire department personnel are both responding."

Police are now directed to use lights and sirens to speed their arrival to medical emergencies; policy includes more specific prioritization of medical care even when the individual might be subject to a mental health hold.

"To us, these steps appear to make practical sense. They also show a commendable ability to glean lessons from experiences in the field, and to make adjustments in an effort to improve future performance," the OIR report concluded.

The report didn't address the lack of transparency by the Police Department and the city to explain the delays to the woman, her husband and the media after the incident, despite many requests for information. The current report also doesn't address the Police Department's and city's lack of an explanation for why Moore's patrol car didn't have dashcam video, which the city claimed doesn't exist.