Two unsettling deaths occurred during elective dental procedures within a year of each other in Arizona and sparked media attention. Both deaths resulted from seemingly routine dental procedures and involved the same nurse anesthetist, Tory Richmond. The deaths occurred in 2019 and 2020.
Following the deaths of the two patients, Richmond was accused of medical negligence and was sued for wrongful death in both cases. One case involved the death of a female patient, Sharlon Stemmons, who died due to insufficient oxygen reaching her brain, while the other case involved a man, Ralph Chapman, whose mouth caught on fire during a dental surgical procedure. The outcomes of the malpractice lawsuits are not known, but Arizona’s Board of Nursing cleared Richmond of any wrongdoing after a thorough investigation and public hearing.
Two Unusual Dental Anesthesia Deaths Draw Scrutiny
Two fatalities resulting from elective dental procedures within a short span is a rare and worrying occurrence. Studies have shown that dental anesthesia deaths are exceedingly rare, with somewhere around 3 in 1,000,000 mortality rates.
However, the Arizona Board of Nursing effectively exonerated Richmond, issuing only a non-public letter of concern. Notably, one board member openly expressed empathy for Richmond during a public hearing, praising his care in one of the cases. Whether this is just a case of bad luck isn’t clear, but lawsuits were filed by the families of the decedents nonetheless alleging wrongful death and medical negligence.
The First Dental Death: Oxygen Deprivation After Dental Anesthesia Issues During a Tooth Extraction Procedure
On October 25, 2019, Sharlon Stemmons, aged 71 at the time, was undergoing a dental procedure under the care of Dr. Ehsan Pourshirazi to have her teeth removed so that she could be fitted with dentures. Dr. Pourshirazi hired Richmond to administer anesthesia through his company, Lifeguard Anesthesia.
According to records, Dr. Pourshirazi's office was not authorized to conduct sedation procedures, which obviously became an important fact after the death of Stemmons. During the operation, Stemmons stopped breathing. Emergency services were summoned 11 minutes after the medical crisis began, a fact that would later be brought to light as a potential point of malpractice. The delay, according to the lawsuit, arose from the defendants' hesitancy to bring attention to their illegal practice of unlicensed in-office sedation. Notably, the Arizona Nursing Board found no fault or wrongdoing in the 11-minute delay.
The lawsuit claimed multiple failures on Richmond’s part: inadequate preoperative evaluation, poor administration of anesthesia, and insufficient emergency response. Ultimately, Stemmons never regained consciousness and succumbed to her condition ten days later. Pourshirazi was later embroiled in a separate dispute with the Arizona Board of Dental Examiners over the failure to have proper licenses to administer anesthesia during in-office dental procedures.
The Second Dental Death: A Fire Sparks in the Patient’s Mouth, Causing Inhalation Injuries
On August 28, 2020, within a year of Stemmons’ tragic death, another patient, Ralph Chapman, lost his life following a dental procedure involving Richmond and Lifeguard Anesthesia. This time, the procedure involved oral laser surgery at a different dental office named AZ Perio.
During the dental procedure, Chapman's mouth caught fire. He was rushed to the Arizona Burn Center at Valleywise Medical Center, where he eventually died from complications related to the injuries sustained during the surgery. A lawsuit filed by Chapman's wife alleges that Richmond administered too much oxygen during the laser procedure, which ultimately contributed to the fire and resulting burn inhalation injuries.
Arizona State Board of Nursing Found No Wrongdoing
After the two patients died during the dental procedures, the Arizona State Board of Nursing conducted a full investigation, culminating in a public hearing, and found no unprofessional conduct on Richmond’s part. This declaration, however, does little to allay public concern, especially when one considers that the nursing board issued only a letter of concern rather than a formal disciplinary action.
The Letter of Concern stated that the “Board determined there was insufficient evidence to support direct action, but sufficient evidence for the Board to notify [Richmond’s attorney] of its concern regarding [Richmond].” See Letter of Concern, p. 1. The Letter of Concern went on to state that Richmond “did not sign the anesthesia consent form or sign that he reviewed the pre-anesthesia medical history paperwork” for the two patients that died during the dental procedures. The Letter further stated that “[i]t is standard of practice for the anesthesia provider to sign the pre-anesthesia forms and anesthesia consent after reviewing anesthesia risks with the patient.” Id.
Although the Board didn’t take any disciplinary action against the doctor, it warned that repetition of similar conduct in the future could lead to disciplinary action.
How to Research Healthcare Providers in Florida
With increasing concerns about medical oversight and accountability, it is essential for patients to perform due diligence before selecting a dentist or oral surgeon. Everyone has the ability to look up a dentist or any other medical provider before allowing them to perform a procedure. Here are some of the best practices when it comes to researching a dentist prior to scheduling an appointment.
Look a Dentist Up on Google
Google is a great source of reviews, and it’s a quick and easy way to get a feel for a dentist or medical provider. Try filtering the reviews to 1-star reviews and see if there are any horror stories. This should clue you in on what kind of dentist you’re dealing with.
Also, when you search a dentist by name on Google, you may get other information outside of simple Google reviews. For example, if a dentist has committed a crime or engaged in some other noteworthy conduct, there may be an article about this somewhere.
Look Up Complaints Against the Dentist on the Florida Department of Health’s Website
You can access a dentist’s profile on the Florida Department of Health’s website. It’s a simple process:
- Go to the Florida Department of Health Website.
- Under “Board/Council,” select “Board of Dentistry.”
- Under “Profession,” select “Dental.”
- Then, enter the first and last name of the dentist, as well as any other information you have that could help identify the dentist you’re researching.
- Now, hit “Search.”
- Once you find the dentist you’re looking for, you can go to their profile, where it will have a tab that says, “Discipline/Admin Action.” There, you can see whether the Florida Board of Dentistry has taken disciplinary action.
Search the Orange County Court Records for Dental Malpractice Lawsuits Against the Dentist
Another way you can do some research on a dentist to determine if you want to be under their care is to research whether they’ve had a lawsuit filed against them. You can do this by going to the Orange County Clerk, Court Records Search.
You can type in the dentist’s first name and last name, or you can type in the name of the practice and do a quick search. The Court Records Search contains online docket information from about 1990 to present day.