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Christian McPhate

A matter of closure

Profile image for By Christian McPhate
By Christian McPhate
Richard Evans is shown standing between with his two sons, Ismail, left, and Dexter.Courtesy photo
Richard Evans is shown standing between with his two sons, Ismail, left, and Dexter.
Courtesy photo

Woman presses for details on what lead to husband’s death via lawsuit

EDITOR’S NOTE: This is the second of two stories on the death of Denton resident Richard Evans. The reporting is based on court records, a Denton police detective’s notes, interviews with key participants and audio recordings of two staff members from the Tarrant County medical examiner’s office, which serves Denton County.


Richard Evans’ family buried him five days after he died in the emergency room at Denton Regional Medical Center. The 57-year-old Evans went to the hospital seeking relief from constipation. He died several hours later.

Evans’ funeral was held on a beautiful spring morning at St. Andrew’s Church of God in Christ in Denton, where his family has attended church for generations. It was May 7, 2013, and hundreds of people showed up to remember Evans’ legacy as a former professional football player, community leader and family man.

People filled the lobby area, and the Evans family ran out of printed obituaries to hand out. Elder Kenneth Davis, a former pastor of St. Andrew’s and a family friend, officiated the ceremony, and Evans’ longtime friend Larry Dixon was just one of several former teammates, family members and community members who spoke at the funeral.

Speakers described Evans as a dedicated family man who never missed a day of work even if he was sick, a guy who would give his last dollar to help someone.

The mystery surrounding Evans’ death has been haunting his widow, Regina, for two years now. On Feb. 6, she filed a wrongful death lawsuit in Dallas County district court, claiming Denton Regional Medical Center, Questcare Medical Services, Dr. Regina Rivera, Dr. Folahan Ayoola and Esmeralda Rosende, a traveling nurse, were responsible for her husband’s death.

Regina’s suit seeks between $200,000 and $1 million in damages.

State District Judge Dale Tillery has dismissed Denton Regional as a defendant in the lawsuit, and the hospital has not responded to the Denton Record-Chronicle’s requests for comment on the case. The Evans family’s attorney is trying to reinstate the hospital as a defendant, but the judge has not made a ruling.

The remaining four defendants are saying they did nothing wrong and should not be held liable for Evans’ death.

Evans said she filed the wrongful death suit because nobody would tell her what really happened to her husband in the hours before he died.

“I see Richard’s face. I haven’t forgotten nothing that happened that day. I think about him every day, ” his widow said.


One night in May

The night Evans arrived at Denton Regional, Sherrivon Wiser, the nurse in charge of the ER, reported to police that the patient was complaining that he’d been constipated for several days. It was around 8 p.m., and he looked like he was in pain, but he wasn’t sweating profusely. He looked “pretty stable,” she said.

Wiser told Denton police Detective Daniel Conrad that Evans went for a CT scan that might diagnose his condition. She saw him later that evening, and she noticed he suffered from “guppy breathing,” a nurse’s term for a patient struggling to catch his breath and so agitated that he claws at you, according to the investigator’s notes.

“Imagine the behavior of what a person would be if they were drowning,” Wiser reported.

Wiser told Conrad she repeatedly had to move Evans’ family members out of the way to treat Evans. She finally made it to his bedside and saw a nurse and a respiratory therapist already working on him. Wiser said she radioed for more help and the team moved Evans from the Yellow Zone, the less critical section of the ER, to the Red Zone.

Wiser said they stabilized him and he seemed to be doing fine. His vitals were OK, she told Conrad. They were busy that night, so Wiser left Evans in another nurse’s care. But when she returned, she heard someone yelling for her to come back to Evans’ room.

“[Richard] was crashing,” they said.

Wiser told Conrad that Evans had “coded” — stopped breathing — and the emergency room staff attempted chest compressions, gave medicine and worked on him for quite some time before the doctor finally called it and declared him dead.

Regina and the rest of the Evans family were waiting in hospital chapel. Wiser accompanied Dr. Rivera, the physician in charge of Evans, when she went to tell the family what happened. Wiser described to the detective that the family “was distraught over the awful event.”

“You’re going to pay for this,” Wiser recalled Regina Evans telling them, according to Conrad’s investigative notes.

Wiser said she believed medical mistakes contributed to Evans’ death, according to the investigator’s notes. She called the Tarrant County medical examiner’s office, which serves Denton County, and reported what she thought had happened. She told Conrad that she initially suspected Evans had received too much morphine. Family members weren’t allowed to see Evans’ body because it seemed that the ER was being treated like a crime scene.

Wiser said she blamed herself for what happened. She said she felt she could have saved his life if she had intervened sooner.

Conrad asked about Rosende, the nurse who had administered the morphine to Evans, and Wiser said she had recently returned to the hospital after a stint at another hospital. Rosende was “a traveling nurse.” Conrad’s notes say Wiser admitted she had not adequately monitored Rosende’s actions because she was a seasoned veteran. She assumed Rosende knew what she was doing.

Wiser told Conrad the hospital staff did not know what was wrong with Evans. They had conducted several tests but found nothing.

Wiser also advised Conrad that “medicine was not an exact science.”

The Denton Record-Chronicle obtained 13 pages of Conrad’s investigative notes from Winn Evans, the dead man’s younger brother.


A troubling find

Regina did not believe her husband’s death was an accident. She felt she had found the proof that she needed. In late October 2013, she contacted Conrad at the Denton Police Department and told him that her husband’s nurse, Rosende, had been charged with six violations by the Texas Board of Nursing — and one of those charges involved falsifying documents related to her husband’s death.

Conrad reported he immediately called Toni Frizell, a Texas Board of Nursing investigator. Frizell told Conrad there were allegations and charges involving Rosende’s actions that night in early May. She later sent him a summary of the charges leveled against Rosende.

The Board of Nursing found Rosende had falsely documented administering morphine to Evans and failed to adequately monitor, assess and document the patient’s status and vital signs before, during and after receiving the morphine and Dilaudid, a powerful pain medication.

Rosende administered the drug to Evans six different times between 8:25 p.m. and 10:05 p.m., adding an additional dose of Dilaudid at 10:34 p.m., according to court documents. The medical examiners office reported that Evans was given 24 milligrams of morphine over a period of one hour and 35 minutes.

The nursing board’s investigation also concluded that Rosende failed to document a change in the patient’s mental status — that Evans was out of bed, agitated and disoriented after receiving morphine and Dilaudid intravenously. The board also found she falsely documented that Evans was unresponsive before Narcan was administered “when the patient was actually up, out of bed, agitated and disoriented,” according to the investigator’s notes.

Narcan is an anti-narcotic drug used on patients who overdose on an opiate.

Frizell, however, stressed the charges were not criminal, but that Rosende could face sanctions ranging from remedial training to the loss of a license to practice nursing.

As part of his investigation, Conrad subpoenaed records from Denton Regional Medical Center. In December 2013, he received the results: two spreadsheets from an automated system called Pyxis that tracks medicines dispensed to patients. The first sheet showed the results of dispensed medicine to Evans on the night of his death. Conrad reported Rosende had made five morphine draws from the pharmacy.

The other spreadsheet contained information from the hospital’s overall search of medicine dispensed on May 2, which revealed Rosende had made a sixth withdraw under a patient with the same last name as the 57-year-old victim: S. Evans.

The investigator’s notes, however, do not show if Conrad ever spoke with Rosende about this discrepancy. But he closed the case in early 2014, concluding that no criminal wrongdoing had occurred. Conrad’s superiors would not let the Record-Chronicle interview him about the case.

“I don’t think it was deliberately done,” Regina Evans said Conrad told them when he brought them to the police station to tell them he was closing the investigation.

“It seemed like the charges from the nursing board didn’t even faze him, so we weren’t surprised at all when he closed the case,” Regina Evans said.


Unsettling future

Evans is buried at Oakwood Cemetery in Denton — resting next to his grandmother Mary; his mother, Lucy; and his older sister, Karen. It’s been a year since Denton police closed their investigation. His widow still doesn’t agree with the department’s decision to close the case.

“There is not a night that goes by that I don’t see exactly what happened in that emergency room,” Regina said. “I still see it today. It still hurts that we have no answers.”

She’s continued searching for answers, filing complaints against the hospital staff and sharing her story with media outlets.

In September, the Texas Board of Nursing sanctioned Rosende in connection with Evans’ case. It’s carefully worded decision: “Respondent’s conduct resulted in an incomplete medical record and was likely to deceive other healthcare providers who needed complete information on which to base their care.”

The board’s sanction fell short of suspending Rosende’s license. Instead, it imposed sanctions requiring her to take a total of four remedial nursing classes totaling 21.6 hours. The board also agreed that she could not practice nursing in another state without first obtaining approval from the state of Texas.

Rosende could not be reached for comment. Online searches for her whereabouts suggest she may now live in Florida.

Deputy Police Chief Roger White, who heads the criminal investigation bureau, reiterated Conrad’s finding of no criminal wrongdoing in the Evans case.

“Rosende falsifying documents wasn’t a criminal action,” White said. “We looked at that specifically. It wasn’t intentional. There was no act to deceive. [The falsifying documents] had to do with more of improper checking of medication. She didn’t follow nurses’ protocol. Nothing in the [Texas Board of Nursing’s] report said that she had criminally acted.”

“There is no doubt in our mind [that Rosende didn’t act criminally],” White added. “But it’s still tragic for the family.”

To this day, Regina doesn’t believe her husband’s death was an act of God.

“He went in for constipation and died,” Regina said. “There’s nothing natural about that.”

CHRISTIAN McPHATE can be reached at 940-566-6878 and via Twitter @writerontheedge.