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Sunday, April 14, 2013


When Clinton Ray Richmond fell and cut his forehead on October 3, 2010 at A Forever Recovery in Battle Creek, Michigan, he didn't know his injury wasn't just skin deep.

Richmond developed a subdural hematoma, which continued to progress and worsen until its discovery in a Dearborn, Michigan hospital emergency room nearly 48 hours later. 

That happened only after A Forever Recovery dumped him—alone and seriously injured—at a Detroit airport.

If Clinton Ray Richmond’s life had an anthem, Tom Waits would have sung it. At 53, he was a smoker with a history of cardiac arrhythmia, depression and type II diabetes. The only luck a guy like Clinton Ray Richmond knew was bad, and he wouldn’t recognize a break unless it involved a bone.

Richmond and his wife, Colleen, filed a lawsuit on March 15, 2013, claiming negligent acts committed were the direct cause of the pain, suffering, and injuries he sustained.

Checking In
On September 8, 2010, hoping for a change, Richmond was admitted to the A Forever Recovery (AFR) rehabilitation facility in Battle Creek, Michigan. According to court papers filed on March 15, 2013 in Calhoun County’s 37th Circuit Court, the facility’s medical director, Dr. Stephen Robinson, treated Richmond throughout his admission.

Stephen Robinson, M. D.
Robinson is a graduate of Michigan State University, Wayne State University School of Medicine and University of Michigan. He is the Medical Director of Historic Northside Family Practice.

During a pre-admission breathalyzer test, Richmond blew hot, hot, hot—with a blood alcohol content of .37 he nearly hit the threshold of alcohol poisoning and certain death. The filing states that Richmond “tested positive for Xanax, opiates and Oxycodone”. Richmond reported to Dr. Robinson that he was a daily drinker and his last opiate use was the night before, September 7, 2010.

Since Richmond was unable to give adequate information or medical history to the AFR staff, his wife, Colleen, helped complete his medical history and allergies. An undated history and physical from AFR indicated that Richmond was “negative for headaches, dizziness, unexplained seizures, unexplained faintings and loss of strength”.

Cold Turkey
Without telling Richmond (or informing him of the risks), AFR completely withdrew all pharmacological medications from him upon his admission—no slow taper, just your average shake-and-bake detox.

A few days later, September 13, 2010, Richmond became nauseated and began vomiting. Complaining of “chest pain, shortness of breath and the nausea and vomiting that did not subside”, Richmond was transported by AFR to Battle Creek Health System (BCHS) for evaluation.  Treated by Dr. Joel Goldberg, M. D. in the emergency department, Richmond was evaluated for lower abdominal pain and given medication. ER notes indicated that the “abdominal pain was benign”, and Dr. Goldberg did not believe it was cardiac in nature. Goldberg ordered a chest X-ray and an electrocardiogram during Richmond’s ER admission, and no abnormalities were found.

AFR did not inform BCHS that they had abruptly ceased Richmond’s total opiate and drug use.

And the rooster crowed.

Richmond was released from the BCHS on September 14, 2010 and returned to AFR. Dr. Seth Egelston, D. O. subsequently took Richmond off Ativan, and Richmond was reported in AFR notes as "eating and sleeping well".

However, five days later, on September 19, 2010, an AFR nursing note indicated that Richmond "suffered a seizure lasting approximately two minutes". The notes indicated that although Richmond sustained no bodily injury during the seizure, he did suffer convulsions. Richmond’s pupils were noted to be “sluggishly reactive to light” and he “suffered from slurred speech and altered consciousness”. His gait unsteady following the seizure, Richmond was transferred by AFR to the BCHS emergency room for evaluation and treatment.

Once again, AFR didn’t tell BCHS that they’d stopped giving Richmond his medication shortly after admission on September 8, 2010.

The rooster crowed a second time.

A September 19, 2010 note written by AFR nurse, Jason L. Gumper, RN to the BCHS indicated that Richmond was a client at AFR and being treated for alcohol, benzodiazepine and opiate addiction. Gumper’s letter requested that Richmond “was not to be administered any opiates or benzodiazepines”.

Richmond told the BCHS emergency department that the “withdrawal from benzodiazepines was causing his seizures”, as noted by the ER department on his September 19, 2010 admission. Richmond had a seizure while being treated in the ER and was subsequently given 2 milligrams of Ativan. The physician treating Richmond witnessed his seizure and noted “no postictal activity following the seizure”.

BCHS records indicated the physician also “noted that malingering should be considered” and stated that his final impression was “non-epileptic seizures with a history of poly substance abuse”.

Richmond continued to suffer seizures throughout late September, 2010. On September 20, 2010, an AFR nursing note reported the “Mr. Richmond had two more seizures that were referred to as ‘non-epileptic’.” On September 21, 2010, a nursing note indicated “additional non-epileptic seizures lasting two and a half minutes each, coming twenty minutes apart

On September 22, 2010, Richmond was sent to Dr. Egelston for examination regarding his seizures, and an EEG was scheduled. Dr. Anthony Janas, a graduate of the Iberoamericana University in the Dominican Republic, signed a doctor’s note on September 24, 2010, indicating that Richmond was sent to the BCHS emergency room for “seizure-like activity that would not subside”.

A CT scan was performed on Richmond at the BCHS on September 24, 2010, and revealed “no acute intracranial abnormality”. The study showed “no signs of hemorrhage or edema, no shift in the midline, and no space-occupying lesion”.

In other words, no injury or damage to Richmond’s brain.

During his stay in the BCHS, Richmond had another EEG on September 28, which was “unremarkable although shaking spells suffered by Mr. Richmond over the course of the exam did not correlate with any electrographic findings.” A neurology workup indicated that his seizure activity “did not have neurologic focus”.

Yet again, AFR didn’t tell BCHS that they’d stopped giving Richmond his medication shortly after admission.

The rooster crowed a third time.

Richmond returned to AFR on October 2, 2010, and was noted to be “unsteady on his feet.”

Falling Down
At  6:15 p.m. on October 3, 2010, Richmond was found “on the floor in a pool of blood”. He had a “laceration above his eye” and was able to walk down to an ambulance “but at some point refused to walk”.

An out-of-sequence note dated October 3, 2010 indicated that when the BCHS emergency room was notified of Richmond’s pending return, the physician “indicated that they could not admit Mr. Richmond for pseudoseizures and explained that the client [Richmond] had been found on the floor with a laceration above his eye”. The note indicated Richmond’s pupils were dilated.

Around 7:00 p.m. on October 3, 2010, Richmond arrived at the BCHS emergency department with a cut above his right eye—and an escort.

An AFR nurse accompanying him indicated that Richmond frequently “pretends not being able to walk and mumbles”. The nurse also claimed that Richmond did not like to participate in AFR’s rehabilitation activities and was “quite certain the patient threw himself on the ground today because they were just trying to get him up and participate in the activity and right after that they saw the patient on the floor with a head laceration”.

The BCHS physician assistant who conducted the emergency department examination on Richmond, William Blakeslee, noted “he agreed with the reporting nurse that Mr. Richmond’s activity does not appear consistent with withdrawal-like symptoms and does not appear consistent with a seizure”. Contemporaneous BCHS notes indicate that Dr. Joel Goldberg reviewed, evaluated, and participated in Richmond’s care during his October 3, 2010 admission.

Richmond was discharged, and driven back to AFR at approximately 10:00 p.m. on the evening of October 3, 2010. An AFR nursing note indicated “Mr. Richmond returned to the facility and refused to speak or stand until he assisted from the transport vehicle”. Notes also stated Richmond was “unable to void”.

Around 3:00 a.m. on October 4, 2010, Richmond was found to be “awake and talking to himself”.  At nearly 6:40 a.m. the same day, a nursing note indicated that Richmond was “alone, mumbling, and incontinent of bladder and bowel”.

So, what did A Forever Recovery do for Clinton Ray Richmond?  They kicked him to the curb—literally.

Treat Him and Street Him
At 10:00 a.m. on October 4, 2010, an AFR nursing note said that the facility “contacted Mr. Richmond’s wife to arrange for his discharge”.

Then, less than 36 hours after he’d been found lying on the floor in a pool of his own blood, Clinton Ray Richmond was driven over 100 miles from Battle Creek and dumped by A Forever Recovery at Detroit Metropolitan Airport’s North Terminal—by himself.

Richmond somehow made it through the TSA security check, and tried to board a Southwest Airlines flight back to Los Angeles. A gate agent refused to let him, and called EMS. The emergency run sheet indicated “Mr. Richmond was dropped off by A Forever Recovery at the airport with recent sutures above his right eye”.

Richmond was taken by EMS to Oakwood Annapolis Hospital in Dearborn, MI, where he was coded as a “level 3 trauma” by emergency room staff.

A CT of Richmond’s head showed a “subdural hematoma with a large amount of subdural air”. The study also noted “significant mass effect with transfalcine herniation toward the left side”.

In plain English, Richmond’s brain had shifted in his skull.

Emergency Craniotomy
On October 5, 2010, Richmond underwent a “right craniotomy with evacuation of subdural hematoma”. The operative note reported a “large, acute clotted subdural that was removed using aspiration and suction”.
[NOTE: A craniotomy for subdural hematoma is performed to remove a hemorrhage (blood clot) from around the surface of the brain.  The location of the blood clot is beneath the firm covering of the brain known as the dura mater, and is therefore called subdural hematoma.]

Richmond was discharged from Oakwood Annapolis on October 11, 2010, and admitted to Oakwood Heritage Hospital in Taylor, Michigan, for rehabilitation and was subsequently discharged.

Medical Malpractice Allegations
The suit alleges multiple violations by the medical professionals treating Richmond, among the following:

•A Forever Recovery’s Medical Director Dr. Stephen Robinson: did not inform the Battle Creek Health System that Richmond’s seizures were caused by the rapid and complete cessation of his opiate and other drug use.  As a result, Mr. Richmond’s seizures went uncontrolled and he ultimately fell, leading to a subdural hematoma with subdural air present, mass effect and transfalcine herniation, which resulted in a craniotomy and evacuation

•Dr. Seth Egelston: for each of Richmond’s admissions to the Battle Creek Health System, Egelston was required to provide the emergency room with an adequate history of Mr. Richmond. Egelston was required to transfer Richmond to a facility at which fall protections could be provided to him when his seizures were not able to be controlled. And during his stay at A Forever Recovery and particularly after the onset of Richmond’s seizures, Egelston was required to order a consultation from internal medicine, addiction medicine, neurology, neurosurgery to assess Richmond’s seizure activity.  The suit alleges that Egelston did not.

•Dr. Joel Goldberg: was required to order a neurological consultation after becoming aware of Richmond’s head wound and altered state. The suit alleges that Goldberg failed to “diligently and appropriately test, monitor and assess the condition of Mr. Richmond’s head injury on October 3, 2010, including but not limited to ordering a CT scan and an MRI of his head”.

•William Blakeslee, PA, was required to bring Mr. Richmond to the attention of a neurosurgeon for consultation after his admission to the Battle Creek Health System on October 3, 2010.  In addition, Blakeslee failed to take an adequate history from Richmond and A Forever Recovery staff members on October 3, 2010, and at the time of each of Richmond’s other admissions to the Battle Creek Health System.

•A Forever Recovery: At times pertinent to Richmond’s complaint, Dr. Robinson and Dr. Egelston were agents, apparent agents, ostensible agents of A Forever Recovery. As such, A Forever Recovery is “vicariously liable” for the negligent acts and omissions of Robinson and Egelston, as well as the injuries and damages resulting from those acts/omissions.

•Also named “vicariously liable” are the Battle Creek Health System and Historic Family Physicians.

Richmond and his wife, Colleen, are asking for damages in any amount in excess of $25,000 for each of the eight counts in the filing.

They plaintiffs have demanded a jury trial.


It looks to me like Egelston and Janas have a history of animus.  

It may have just been a delightful locker room towel-snapping incident that went too far, but Dr. Anthony Janas, proud graduate of a Caribbean medical school, filed a petition on November 21, 2011 for a personal protection order (PPO)--against Dr. Egelston!

Janas' petition was denied, and there's no record of an appeal.

Here's a recap, direct from the Calhoun County court system: 

SELECT ALL 3 DOCUMENTS SHOWN BELOW3 documents, aproximately 4 pages in totalTotal USD 11.00
AddDateDescriptionPrice *
Apr-15-2013CASE 2011 0000003601 INFORMATION **5.00
* Enhanced access service fee included in price
** Contains case overview, all parties involved, charges, and register of actions
Party NameParty TypeAttorney of Record
No information available
Events [ Top ]
DateCase Event


  1. What a travesty! Thanks for this in depth report! Keep us posted on the case if you can.

  2. Good to know that the BCHS is on the job! Although dumping a dying man on the street was a nice little flourish on AFR's part.

  3. So when will you be posting....The rest of story? The truth and who really was sued and who was dropped from the lawsuit as the allications were not substantiated