Government’s 404(b) Notice – Page 1

IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF TEXAS

DALLAS DIVISION

UNITED STATES OF AMERICA

v.

RAYNALDO RIVERA ORTIZ JR.

NO. 3:22-CR-378-N

GOVERNMENT’S NOTICE OF

EVIDENCE POTENTIALLY RELEVANT TO RULE OF EVIDENCE 404(b)

The government provides notice that it may introduce evidence at trial regarding 

acts that are intrinsic to the crimes charged or are otherwise admissible under Federal 

Rule of Evidence 404(b). As set out below, some of these acts arose out of the same 

series of events as the charged offenses, are inextricably intertwined with the evidence 

regarding the charged offenses, and are necessary to complete the story of the charged 

crimes. Evidence of the acts described below also would be admissible pursuant to 

Federal Rule of Evidence 404(b).

Factual Background

The charges in this case stem from the defendant tampering with and 

contaminating medical IV bags used in surgical procedures at Baylor, Scott, & White 

Surgicare North Dallas facility (“BSW Dallas”). Dkt. 17 at 6. The indictment generally 

alleges that the defendant tampered with a consumer product causing serious bodily 

injury and intentionally adulterated a drug having a reasonable probability of causing 

serious adverse health consequences by injecting adulterants into the IV bags of saline 

solution. Id. at 6-7. 

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As alleged in the indictment, multiple incidents of cardiac emergencies occurred at 

BSW Dallas between May and August 2022 during otherwise routine surgeries. Id. at 3. 

The incidents occurred shortly after an IV bag from the “warmer”—a small refrigeratorsized device that warms IV bags for surgery—was attached to the patient via a tube with 

a needle inserted into the patient’s vein. Id. at 4. On or about August 25, 2022, hospital 

staff discovered two IV bags in the warmer with small puncture holes in their outside 

wrappers. Id. at 5. Chemical testing of the liquid in those IV bags revealed the presence 

of pharmaceutical adulterants that are not ingredients included in lactated ringer’s IV 

solution. Id. Surveillance videos show the defendant surreptitiously and inexplicably 

placing IV bags in the facility’s warmer minutes before nurses took bags out of the same 

warmer and administered them to the patients who experienced cardiac emergencies. Dk. 

16 at 21-22.

Ortiz was a licensed anesthesiologist who, since the 1990s, had frequently 

provided medical services to surgical patients at BSW Dallas and other surgical facilities 

in the area. Id. at 1. In 2016, Ortiz was convicted of shooting his neighbor’s dog, a 

violation of Texas animal cruelty laws. Also in 2016, BSW North Garland, one of the 

surgery centers at which Ortiz practiced, suspended Ortiz for 14 days for failing to 

disclose his arrest on the animal-cruelty charges to the center. In 2018, the Texas 

Medical Board instituted disciplinary proceedings against Ortiz based on his failure to 

disclose his criminal conviction to the Board. The Board eventually imposed discipline, 

including a public reprimand, a fine, a series of disclosure requirements, and a 

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requirement to adhere to professional obligations, as well as the Texas Medical Practice 

Act. 

Then, in November 2020 at BSW North Garland, Ortiz committed a grave medical 

error that resulted in a serious patient injury. Days after that incident and then again days 

after the hospital opened an investigation into the incident, medical professionals at BSW 

North Garland noted unusual medical complications during which patients in the preoperative area experienced extreme hypertension and tachycardia after being attached to 

IV bags prior to their surgeries.

Instead of facing BSW North Garland’s internal disciplinary process for his 

conduct in the November 2020 incident, Ortiz voluntarily relinquished his privileges at 

BSW North Garland in April 2021—but was still subject to pending disciplinary 

proceedings before the Texas Medical Board related to the same medical error. 

Then, in May 2022, just days before the cardiac emergencies described in the 

indictment began occurring at BSW Dallas and while the Board’s investigation into the 

November 2020 incident was still ongoing, Ortiz committed yet another grave medical 

error that resulted in a serious patient injury at BSW Dallas. Ortiz quickly found himself 

again under investigation—this time by the Medical Executive Committee at BSW

Dallas. By this time, revenue for Ortiz and his anesthesia and billing businesses had been 

in decline, Ortiz owed millions of dollars in back taxes (but continued to spend money 

profligately), and BSW Dallas was Ortiz’s primary source of income. The poisonings at 

BSW Dallas began just days after Ortiz discovered he was the subject of this new 

disciplinary proceeding.

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Notably, the Texas Medical Board proceeding against Ortiz based on the 2020 

incident at BSW North Garland was still pending at the time of nearly all the events 

described in the indictment. On August 19, 2022, the same day Ortiz poisoned victim 

K.P. with an IV bag at BSW Dallas, the Texas Medical Board issued an order finding that 

Ortiz “did not respond to the patient’s issues in an appropriate manner,” “failed to 

document the critical events,” and “did not recognize the patient’s inadequate 

oxygenation and ventilation.” In the order, Ortiz agreed to several conditions, including 

submitting to extensive ongoing monitoring by a Board-selected physician at Ortiz’s 

expense, re-taking a Medical Jurisprudence Examination given by the Texas Medical 

Board, completing 16 hours of continuing medical education credits, and paying a 

penalty of $3,000. 

Proffered Evidence

As relevant to Rule 404(b), the government may elicit testimony or present the 

following categories of evidence, each of which is described in more detail below:

1. Documents from earlier disciplinary actions that include the fact of a prior 

conviction and Ortiz’s failure to report that conviction;

2. Ortiz’s 2020 and 2022 medical errors, including documents from 

disciplinary proceedings involving those medical errors that were pending 

at the time of the crimes in the indictment;

3. Ortiz’s failure to pay federal income and state property taxes;

4. Two prior similar poisonings at BSW North Garland that occurred under 

the same general circumstances as the BSW Dallas poisonings;

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5. Multiple other cardiac incidents at BSW Dallas and the death of Dr. 

Melanie Kaspar in June 2022 due to bupivacaine poisoning.

Relevant Law

“‘Other act’ evidence is ‘intrinsic’ when the evidence of the other act and evidence 

of the crime charged are ‘inextricably intertwined’ or both acts are part of a ‘single 

criminal episode’ or the other acts were ‘necessary preliminaries’ to the crime charged.” 

United States v. Williams, 900 F.2d 823, 825 (5th Cir. 1990); United States v. Kloock, 

652 F.2d 492, 494-95 (5th Cir. 1981). Such evidence “is admissible so that the jury may 

evaluate all of the circumstances under which the defendant acted.” United States v. 

Randall, 887 F.2d 1262, 1268 (5th Cir. 1989). Intrinsic evidence does not implicate Rule 

404(b), and consideration of its admissibility pursuant to Rule 404(b) is unnecessary. 

United States v. Coleman, 78 F.3d 154, 156 (5th Cir. 1996).

Federal Rule of Evidence 404(b) provides that evidence “of a crime, wrong, or 

other act is not admissible to prove a person’s character in order to show that on a 

particular occasion the person acted in accordance with the character,” but such evidence 

may be admissible “for another purpose, such as proving motive, opportunity, intent, 

preparation, plan, knowledge, identity, absence of mistake, or lack of accident.” Fed. R. 

Evid. 404(b)(1)-(2). As courts have routinely stated, Rule 404(b) is a “rule of inclusion.” 

United States v. Andersen, 374 F.3d 281, 288 (5th Cir. 2004). In other words, a court 

may admit prior crimes or bad acts evidence if it is “relevant for any purpose other than 

proving the defendant’s propensity to commit crimes.” United States v. GutierrezCase 3:22-cr-00378-N Document 66 Filed 03/06/24 Page 5 of 17 PageID 696
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Mendez, 752 F.3d 418, 423 (5th Cir. 2014). This is known in the Fifth Circuit as the first 

part of the two-part Beechum test.

Evidence admitted pursuant to Rule 404(b) must also “possess probative value that 

is not substantially outweighed by its undue prejudice” under Federal Rule of Evidence 

403. United States v. Beechum, 582 F.2d 898, 911 (5th Cir. 1978). In performing this 

second part of the Beechum test, “the task for the court . . . calls for a commonsense 

assessment of all the circumstances surrounding the extrinsic offense.” United States v. 

Richards, 204 F.3d 177, 200 (5th Cir. 2000). The risk of unfair prejudice is substantially 

lowered by a district court’s limiting instruction. United States v. Crawley, 533 F.3d 349, 

355 (5th Cir. 2008). 

Argument

Ortiz’s motive and intent will be key areas of contention at the upcoming trial. 

Due to the unique circumstances of the crimes charged in the indictment and the 

considerable trust the public puts in medical professionals, the government must be able 

to convey to the jury the circumstances under which Ortiz acted and the motives he had 

for doing the unusual acts alleged in the indictment. Put simply, the government is 

entitled to explain to the jury, using competent evidence, why a licensed physician would

transform from someone who treats patients into someone who hurts them.

The evidence in this notice is admissible in two ways. First, the evidence is 

inextricably intertwined with the charged offenses and provides background information 

to complete the story of the charged offenses. Alternatively, the evidence is admissible 

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pursuant to Federal Rule of Evidence 404(b), as it proves a common plan or scheme and 

proves the defendants’ motive, knowledge, intent, and absence of mistake or accident.

1. Documents from earlier disciplinary actions that include the fact of a 

prior conviction and Ortiz’s failure to report that conviction

As described above and as the government plans to present at trial, in the years 

leading up to the events at issue in the indictment, Ortiz was the subject of multiple 

disciplinary proceedings: a 2016 investigation by BSW North Garland, a 2018

investigation by the Texas Medical Board, a 2020-21 investigation by BSW North 

Garland (which led to Ortiz resigning his privileges there), and a 2021-22 investigation 

by the Texas Medical Board (which was still pending at the time of the crimes in the 

indictment). 

These investigations by themselves had already put Ortiz’s medical license, his 

privileges, and his employment as a physician—his primary source of income and the 

only way he could fund his opulent lifestyle—at risk. As the government plans to 

present, when Ortiz committed the subsequent medical error at BSW Dallas on May 19, 

2022 and the Medical Executive Committee there quickly began yet another 

investigation, the situation was extremely grave for his future both as a doctor and, by 

extension, as a wealthy individual. The series of poisonings charged in the indictment 

began just days later. Hence, as the government plans to show, Ortiz’s motive was to

take revenge on the medical center and on the people whom he believed were unfairly

investigating him—by surreptitiously hurting their patients and by causing chaos at BSW 

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Dallas, while simultaneously attempting to deflect attention from his own medical errors

by making sure that he did not poison any of his own patients. 

As to this first category of disciplinary evidence, the government plans to present 

evidence and testimony that Ortiz failed to disclose to BSW North Garland and to the 

Texas Medical Board his 2016 conviction for shooting his neighbor’s dog. The 

government recognizes that, for the purposes of affirmative Rule 404(b) evidence in the 

government’s case-in-chief1, disclosing to the jury that Ortiz shot his neighbor’s dog 

could carry the risk of undue prejudice. Hence, the government proposes redacting the 

documents at issue to identify only that Ortiz was disciplined for failing to report a 

criminal conviction; a proposed redacted Texas Medical Board document is attached as 

Exhibit A.

As the first dominos to fall in the snowballing disciplinary proceedings against 

Ortiz that continued until the time of the crimes charged in the indictment, the 

disciplinary proceedings in 2016 and 2018 are critical indicators of Ortiz’s intent and 

motive in committing the acts charged in the indictment, and are proper evidence of 

motive, knowledge, and intent that should be admitted under Rule 404(b). As to Ortiz’s 

intent and motive, the jury is entitled to hear not just that Ortiz was subject to one

pending disciplinary proceeding at the time of the crimes charged in the indictment, see

infra, but also that he was the subject of multiple, cascading investigations that made the 

1 The government reserves the right to seek admission of Ortiz’s conviction for shooting his neighbor’s 

dog—as well as other aspects of his history, including multiple domestic-violence issues—through any 

other viable theory, such as the defense opening the door to its admission by arguing that Ortiz is a 

peaceful person or a person of good character.

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May 2022 incident all the more dangerous to his future as a doctor and gave him all the 

more reason to cause chaos at the surgical center—as well as to make it appear as if there 

were systemic problems at the center unrelated to Ortiz. 

As to Ortiz’s knowledge, the government also plans to present evidence about how 

rare disciplinary actions against doctors are—roughly 30 Texas doctors per year are 

disciplined out of more than 90,000 doctors—further underscoring the unusual nature of 

Ortiz’s problems and his motivation to avoid future discipline. The government is 

entitled to tell the full story of the crimes charged in the indictment and explain Ortiz’s 

motive by informing the jury that Ortiz, unlike the vast majority of other doctors, was 

under an extremely heightened risk of losing his privileges and/or medical license due to 

escalating discipline, which includes the story of the earlier discipline proceedings. 

There is little to no risk of undue prejudice as to this evidence because disciplinary 

proceedings against Ortiz due to failure to report a criminal conviction are not “highly 

prejudicial” or “incendiary,” nor are they “of a heinous nature,” and this proposed Rule 

404(b) evidence of other wrongs is of a magnitude far lesser than the charged offenses, 

which are extremely serious. United States v. Pruett, 681 F.3d 232, 245 (5th Cir. 2012). 

A limiting instruction could also appropriately address any concerns about prejudice.

2. Ortiz’s 2020 and 2022 medical errors, including documents from 

disciplinary proceedings involving those medical errors that were 

pending at the time of the crimes in the indictment.

The government intends to present evidence of Ortiz’s prior medical errors in 

November 2020 and May 2022. As described above, in November 2020, Ortiz was the 

anesthesiologist for a procedure at BSW North Garland during which a patient suffered 

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serious complications during anesthesia. The Texas Medical Board inquiry into that 

incident was pending during the crimes charged in the indictment.

Also as described above, a second critical medical incident involving Ortiz 

occurred on May 19, 2022 at BSW Dallas. That incident led to a disciplinary inquiry that 

was initiated days before the cardiac incidents at issue in the indictment. The 

government may elicit testimony that Ortiz was informed of the disciplinary inquiry 

against him related to the May 19 incident on or around Tuesday, May 24, 2022, and the 

first cardiovascular incidents occurred on or around Thursday and Friday, May 26 and 

27, 2022, later the same week.2 The government may also elicit testimony that Ortiz

losing his job at BSW Dallas would have been (and was) financially devastating to Ortiz.

This is core intrinsic evidence, and therefore not subject to a Rule 404(b) analysis, 

because the prior medical errors (and/or the disciplinary investigations into them) overlap 

with the crimes charged in the indictment, complete the story of the crimes charged in the 

indictment, and show the circumstances under which Ortiz acted. Randall, 887 F.2d at 

1268. The government’s theory of the case—strongly supported by objective evidence—

is that Ortiz began poisoning patients at BSW Dallas shortly after the investigation into 

the May 2022 incident occurred and almost immediately after Ortiz found out about it. 

There is no way to explain that to the jury without discussing circumstances of the May 

2022 incident at BSW Dallas.

2 Further, Ortiz appeared at another meeting related to the May 19 incident on or around Wednesday, June 

22, 2022, and there was a suspected cardiovascular incident the following week on or around Monday, 

June 27, 2022. 

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Even if this evidence were subject to a Rule 404(b) analysis, it is properly 

admissible because it is substantially probative of Ortiz’s intent, knowledge, and motive 

in committing the tampering and adulteration charges in the indictment. That is, the 

investigations into the medical errors and Ortiz’s reaction to them provide a powerful 

motive for Ortiz to somehow take revenge on the center and/or to attempt to deflect 

attention away from his own errors.

3. Ortiz’s failure to pay taxes.

The government intends to present evidence that, at the time of the crimes charged 

in the indictment, Ortiz owed millions of dollars to the IRS, his house was encumbered 

by a federal tax lien during the relevant period, and Collin County had sued Ortiz on 

multiple occasions to recover unpaid taxes. According to public records, the IRS has 

filed multiple federal tax liens on property belonging to Ortiz, including in August 2021

and January 2022. The government does not plan to dwell on this evidence, but will 

present it as part of Ortiz’s motive to preserve his income from practicing medicine at 

BSW Dallas. 

This evidence is intrinsic because it shows that Ortiz was in financial distress at 

the time of the crimes charged in the indictment, and therefore it “completes the story” of 

the crimes and shows “the circumstances under which [Ortiz] acted.” United States v. 

Gurrola, 898 F.3d 524, 536 (5th Cir. 2018) (evidence is intrinsic if it “arose out of the 

same transaction or series of transactions as the charged offense, if it was inextricably 

intertwined with the evidence regarding the charged offense, or if it is necessary to 

complete the story of the crime of the trial.”). 

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Even if this evidence is subject to a Rule 404(b) analysis, however, it passes that 

test because it shows Ortiz’s motive. Indeed, Ortiz had a powerful motive to deflect 

attention away from his May 2022 medical error by making it look like other doctors 

were committing medical errors at BSW Dallas. That is, he wished to stave off losing his 

privileges at BSW Dallas so he could maintain his opulent lifestyle, despite his financial 

problems. The evidence of Ortiz’s financial situation is probative of Ortiz’s motive and 

admissible for a proper purpose under Rule 404(b).

4. Two similar poisonings at a different surgical center.

The government may elicit evidence and testimony that, days after the November 

2020 error that Ortiz committed at BSW North Garland and then again days after that 

surgery center opened an investigation into the error, medical professionals there noted

highly unusual medical complications during which patients in the pre-operative area 

experienced extreme hypertension and tachycardia after being attached to IV bags prior 

to their surgeries—almost exactly like the later victims at BSW Dallas. Those medical 

professionals will testify that Ortiz was at BSW North Garland at or around the time of 

those incidents.

These incidents easily pass the test for Rule 404(b) because they demonstrate a 

unique and unusual modus operandi, as well as “preparation, plan . . . identity, absence of 

mistake, [and] lack of accident.” Ortiz’s potential earlier dry run of poisoning patients at 

BSW North Garland after committing a grave medical error there—and then again after 

finding out about a disciplinary action there—belies any contention that the poisonings in 

the indictment at BSW Dallas were the work of anyone other than Ortiz, or that they were 

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the result of happenstance or misfortune. Nor will evidence about the prior poisonings 

cause undue prejudice because they are essentially part of the same criminal scheme as 

the charges in the indictment, so they will not independently or inappropriately “excite[]” 

the “emotions of the jury” given their similarity to other pieces of relevant evidence in 

the case. United States v. Cockrell, 587 F.3d 674, 679 (5th Cir. 2009) (affirming the 

admission of Rule 404(b) acts that were extremely similar to the charged conduct). 

Furthermore, the probative value of Ortiz committing other similar crimes with such a 

unique modus operandi is high, which counsels for this evidence’s admission. Id.

5. Ten other cardiac incidents, and the death of Dr. Melanie Kaspar.

The government plans to introduce evidence of ten other suspected incidents 

between May and August 2022 where patients experienced unexpected cardiovascular 

complications, including the death of Dr. Melanie Kaspar. As alleged in the indictment, 

Dr. Kaspar, a 55-year-old who worked as an anesthesiologist at BSW Dallas, suffered 

cardiac arrest on June 21, 2022, approximately 30 minutes after administering IV fluids

to herself at home. She died before emergency personnel arrived on the scene. There 

were no injuries to suggest a traumatic cause of death, no evidence that Dr. Kaspar had 

any underlying significant medical issues, and no gross anatomic findings on autopsy to

explain her death. Dr. Kaspar sometimes used IV bags from work when she felt unwell 

and had tolerated them in the past.

Bupivacaine was found in her post-mortem toxicology analysis. Bupivacaine is 

not a drug of abuse, and according to medical professionals, it is highly unlikely that a 

medical professional would knowingly inject herself with bupivacaine intravenously. 

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The circumstances of her death did not indicate that she desired to commit suicide. The 

Dallas County Medical Examiners concluded that Dr. Kaspar died from the toxic effects 

of bupivacaine and the manner of death was a homicide.

Following the autopsy report on Dr. Kaspar’s death, and the August 24, 2022 

incident involving J.A., as charged in the indictment, BSW Dallas personnel identified 

that the incidents were likely not isolated and were part of a pattern of intentional 

adulteration of IV bags. BSW Dallas personnel determined that there were at least ten 

other suspected incidents between May and August 2022 where patients experienced 

unexpected cardiovascular complications during otherwise unremarkable surgeries. 

According to medical professionals, ten cardiac events during otherwise unremarkable 

surgeries at BSW Dallas is a high and unnatural number of anesthesia complications in 

such a short time period. 

The incidents generally seemed to follow the same pattern—a patient’s blood 

pressure would spike to dangerous levels at some point during the surgery, usually after 

the placement of a new IV bag. Typically, medical staff was able to save the lives of 

these patients only by using the “crash cart”—a set of emergency tools used when 

complications arise during surgeries—and by transferring the patients to emergency 

medical facilities. BSW Dallas personnel also determined that the cardiac incidents 

seemed to occur mostly during longer surgeries, when the patients required a second or 

subsequent IV bag retrieved from the “warmer.”

The government intends to introduce evidence that, in addition to the events 

occurring on May 26, 27, and June 27 described above, the other cardiovascular incidents 

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involving suspected compromised IV bags occurred on or around July 7, 15, and 18. 

Ortiz performed services at BSW Dallas on or around—or on or around days leading up 

to—those days. Notably, Ortiz was on vacation from on or around July 23 until on or 

around July 28, 2022. No cardiovascular events occurred during this time, but did start 

occurring again after he returned to BSW Dallas on or around July 29, 2022; the first 

suspected incident thereafter occurred on or around August 1, 2022. 

Because these episodes are charged in the indictment and are part of the same 

criminal episode as Ortiz’s conduct charged in the indictment, this evidence is not subject 

to a Rule 404(b) analysis. The government includes them in this notice out of an 

abundance of caution. United States v. Williams, 900 F.2d 823, 825 (5th Cir. 1990). But 

even if the evidence about the other poisonings at BSW Dallas were subject to a Rule 

404(b) analysis, the evidence would easily pass the test because they are offered for a 

proper purpose. That is, the pattern of incidents demonstrates the “identity” of the person 

responsible for the poisonings, as well as Ortiz’s “opportunity” to commit the crimes. 

This evidence demonstrates that the poisonings began days after Ortiz was informed of 

the disciplinary inquiry into the May 2022 incident; they occurred on or around days that 

Ortiz worked at BSW Dallas; and they ceased while Ortiz was on vacation in late July 

2022. 

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Respectfully submitted,

LEIGHA SIMONTON

United States Attorney

JOHN J. DE LA GARZA

Assistant United States Attorney

Texas State Bar No. 00796455

1100 Commerce Street, Suite 300

Dallas, Texas 75242

214-659-8838

s/ Patrick R. Runkle

PATRICK R. RUNKLE

Senior Litigation Counsel 

RACHEL E. BARON

Trial Attorney

Consumer Protection Branch

U.S. Department of Justice

P.O. Box 386

Washington, DC 20044-0386

202-532-4723

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CERTIFICATE OF SERVICE

I certify that on March 6, 2024, I electronically filed this document with the Clerk for the 

United States District Court for the Northern District of Texas pursuant to its electronic 

filing system (ECF). The ECF sent a “Notice of Electronic Filing” to the attorneys of 

record who have consented to accepting service via this method. 

s/ Patrick R. Runkle

Patrick R. Runkle

Senior Litigation Counsel 

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