Although Taylor Moorehead, chief of the department's custody division, says that he's "comfortable" that resuscitation was attempted before the arrival of the doctor and paramedics, he could offer no proof that it had, other than a falsified nurse's report, which he readily concedes has "no credibility at all." However, Principal Deputy County Counsel Kevin Brazile, who represents the Sheriff's Department, says that the doctor and paramedics arrived at about the same time, and that until they did so, there was a delay of 5 to 15 minutes before any resuscitation was attempted. Moorehead says that if such a delay occurred, it is "unconscionable."
Equally unconscionable, in Moorehead's view, is the action of a nurse who entered the room following the strapping and shot Evans full of his two milligrams of prescribed Ativan, after he was dead. "How can you give a shot to a person who's in cardiac arrest and not even check his vitals?" Moorehead asks. "That's criminal." In any case, Evans' body never absorbed the medication, and no drugs of any kind were found in his system.
Much of the immediate fault for Evans' death might be laid at the feet of Eulalia Cristobal, the registered nurse in charge that night, who, under jail regulations, was supposed to ensure that a nurse was in the strapping room monitoring the prisoner's condition. Her failure to do so, for reasons that aren't clear, and her subsequent falsification of Evans' medical records led to her forced resignation. She also pleaded no contest to a misdemeanor charge of filing a false report. A second nurse is under investigation.
For the Record
Los Angeles Times Sunday September 23, 2001 Home Edition Los Angeles Times Magazine Page 6 Times Magazine Desk 2 inches; 39 words Type of Material: Correction
In "How California Failed Kevin Evans" (by Joe Domanick, Aug. 26), it was incorrectly reported that Evans died in the forensic inpatient unit of the county jail's Medical Services Building. The death occurred in a strap-down room of the building, one floor below the forensic unit.
But the questions enveloping Evans' death don't stop at the nurses. None of the deputies or Department of Mental Health professionals involved knew of Evans' medical, psychiatric or arrest history. As the struggle occurred, Hollis, the sergeant in charge of the strapping, was far from assertive. Instead, deputies were giving orders to each other. It was a tough, ugly thing they had to do, and as they did it, there was no obvious angry or gratuitous brutality, no "give him one to remember you by," as New York cops used to say. Yet there was something deeply troubling about the robotic manner in which the deputies went about their jobs, as if the by-the-numbers completion of the task was the mission, as opposed to an end result that was safe not only for themselves, but for Evans as well. They were professional as they understood it. But professional at what?
They failed to tell Evans, for example, what was about to happen, or to reassure him that he shouldn't be afraid. They focused on getting the restraint done, and overlooked his dying gasps. Moorehead later summed up the attitude. "The gasps and the moans from somebody who puts up that kind of resistance [is] not uncommon" and "shouldn't be characterized as a last gasp." He himself, he said, "had heard those sounds as a young deputy doing restraints."
Maybe trained mental-health professionals or medical personnel would have recognized the difference--and that, ultimately, is the point. To blame Evans' death solely on his treatment at the jail is to miss the profoundly larger issue: Why was a homeless, schizophrenic man--one with lifelong physical troubles and one who had been arrested or cited 13 times essentially for trying to exist on the streets of the Antelope Valley--taken to county jail instead of a medical or mental-health facility?
From the moment he was born with cerebral palsy, Kevin Evans' life had been full of trouble. He'd stopped breathing several times during birth, and, according to Lambey, emerged weighing a sickly 3 pounds. He was so small, in fact, that his grandmother could place him on a miniature pillow and hold him in the palm of one hand. A series of surgeries left his legs twisted, huge scars on the backs of knees and calves, his toes pointed inward, and Evans unable to walk in a straight line.
Following the incident with the hot dog, Evans left his mother, three sisters and their crowded two-bedroom South-Central apartment. Lambey says he never spoke again with their mother, who has since died. After a stint living in a windowless, bug-infested abandoned car, he was taken in by the family of a neighbor who was a licensed vocational nurse. Despite her care, Evans grew worse. He stopped talking to people and engaged instead in long, mumbling, frequently unintelligible conversations with himself. He'd become enraged if he saw someone wearing the color purple, and, as his sister recalls, forgot such simple facts as his age.