1	Background Information Pertaining to the Forensic Investigation into the Death of Anna Nicole Smith
2	Initial Information Anna Nicole Smith found unresponsive at Seminole Hard Rock Hotel and Casino Possible “stomach flu” for several days Body transported to Memorial Regional Hospital Pronounced dead and Medical Examiner’s Office notified at 2:49 PM February 8, 2007
3	Medical Examiner Jurisdiction Dictated by Florida Statute 406.11 The medical examiner of the district in which the death occurred . . . shall determine the cause of death . . . when any person dies: suddenly, when in apparent good health in suspicious or unusual circumstances unattended by a practicing physician
4	Medical Examiner’s Office Immediate Response Dispatched Dr. Gertrude Juste, Associate Medical Examiner, to the scenes (hotel and hospital) Many prescription drugs recovered in hotel room; no illegal drugs Dr. Juste accompanied body from hospital to morgue Activated high-profile security precautions with Broward Sheriff’s Office Developed autopsy checklist
5	Patient Received at M.E. Facility Brought in at 4:59 PM under routine protocol in manner preserving dignity of the deceased Assembled Forensic Team Initial documentation started Brief external examination No evidence of blunt force, sharp force, gunshot wound, or asphyxiation Samples taken for microbiology, toxicology, serology, DNA, trace evidence
6	Forensic Team
7	Evening of February 8, 2007 Body and tissue samples secured in locked area of morgue Autopsy scheduled for next morning approximately 9:30 AM Final autopsy checklist developed and reviewed
8	Autopsy: February 9, 2007 Forensic Team present Prosectors: Dr. Joshua Perper and Dr. Gertrude Juste Autopsy commenced at 10:36 AM, ended 6 hours later
9	Autopsy: February 9, 2007 (Cont’d) Extensive sampling of tissues and body fluids for toxicological analysis Additional samples for DNA Cultures of organs and internal body fluids for evidence of infection Detailed examination of body cavities and all organs Samples taken for microscopic evaluation
10	Initial Autopsy Findings
11	Microscopic Findings Heart: minimal, focal heart muscle scarring; likely clinically insignificant Lungs: mild terminal aspiration; patchy edema Mild chronic duodenitis (minimal intestinal inflammation) Slightly increased number of acute inflammatory cells in spleen (consistent with infection) Chronic inflammation of thyroid gland (Hashimoto thyroiditis)
12	Volunteering Medical Consultants
13	Evaluation by Consultants Two cardiopathologists examined the heart in detail No significant gross or microscopic abnormalities other than minimal focal scarring in one of many slides (deemed clinically insignificant; found in many normal hearts if extensively sampled) and a tiny focus of chronic inflammation on one slide of many Neuropathologist examined the brain and found no obvious lesions to explain death
14	Some of the Conditions Excluded by Autopsy and Tests Pneumonia Pulmonary thromboembolism Asthma Coronary artery disease Heart problems Stroke Cancer Large amounts of pills in the stomach
15	Investigation into Circumstances of Death 12 individuals interviewed (friends, physicians, witnesses) Bottles of medication from U.S.A. and Bahamas examined Dr. Gertrude Juste and investigator Wendy Crane traveled to Bahamas to conduct additional interviews & review medical records Review of Seminole Police Investigation file Forensic examination of two of Miss Smith’s laptop computers Developed detailed timeline leading up to death
16	Social and Medical History Information obtained from witnesses and public sources: Chronic pain Long term prescription drug use Questionable “seizure” history (possibly related to medications) Fluctuating weight Stressors: public scrutiny, protracted lawsuits
17	More Recent Events Prescription drug use, including Methadone, during recent pregnancy Birth of daughter, Dannielynn, September 2006 Death of son, Daniel, 3 days later—emotionally devastating, depression Near drowning episode in October 2006 associated with probable drug intoxication resulting in pneumonia
18	The Last Few Months Continued use of multiple prescription drugs Continued injections of various “longevity medicines” and diet medications, including Vitamin B12, Growth Hormone, Topamax, and immunoglobulins Suicidal comments in short-term after son’s death Mood variable but improving Additional stressors: Paternity suit, suit regarding ownership of residence in Bahamas, inheritance suit re: husband’s estate
19	The Final Week New stressor: Lawsuit filed against TrimSpa Ongoing paternity, estate, and residential lawsuits While in Bahamas, had injections into buttocks of B12, Human Growth Hormone, or immunoglobulins Planned trip from Bahamas to Fort Lauderdale on Monday, February 5, 2007
20	Timeline: Monday, Feb 5, Morning Prior to flight from Bahamas to U.S. felt well with no complaints for the 3 days prior to flight 11:00 AM had dance lesson in preparation for music video and participation in TrimSpa celebration in Bahamas Planned to shop for furniture in Miami for her Bahamas home Stated intention to marry Howard K. Stern on February 28, 2007 (per statement of Dr. Eroshevich, psychiatrist and friend) Prior to flight injected left buttock with either vitamin B12, human growth hormone, or immunoglobulins (longevity/immune protective medications)
21	Timeline: Monday, Feb 5, Early Evening Flew from Bahamas to Ft. Lauderdale with Howard K. Stern and Dr. Eroshevich (psychiatrist and friend) Due to pilot’s error, plane landed in Miami at 5:30 PM During flight very upbeat and outgoing, however complained of pain in left buttock when seated Complained of cold and severe chills in limo ride to Seminole Hard Rock Hotel; checked in at 7:30 PM Upon arrival to room, temperature of 105 degrees; refused to go to hospital or let friends call 911 Placed in ice bath, temperature dropped to 97 degrees
22	Timeline: Monday, Feb 5, Late Evening Administered TamiFlu Cipro (ciprofloxacin), 1000 mg, an antibiotic Fluids Fell asleep at 10:00 PM after a dose of chloral hydrate (sleeping medication) Recommended dose is 1 to 2 teaspoons prior to bed Her routine dose was 2 tablespoons taken as needed (though she sometimes drank directly from the bottle)
23	Timeline: Tuesday, Feb 6 Next morning, companions noted a “pungent odor” emanating from Anna Nicole, apparently sweat soaking the sheets Little if any urine production Temperature 100 degrees Given a bath and oral hydration; pungent odor faded Appeared to be doing OK but no appetite; watching TV Felt well in early afternoon; took chloral hydrate and slept for 2 hours
24	Timeline: Tuesday, Feb 6, Evening Watched TV with Howard K. Stern and Dr. Eroshevich until 11:00 PM Took another dose of chloral hydrate (sleeping medication) Asked for and received (unknown if she took them): Soma (muscle relaxant for painful musculoskeletal conditions) Klonopin (anti-seizure and anti-anxiety drug) Valium (anti-anxiety drug) Topamax (anti-seizure; tranquilizer; used in weight reduction)
25	Timeline: Wednesday, Feb 7 Awake in bed and watching TV at 11:00 AM Ate breakfast (egg white omelette with spinach) Found naked and confused sitting in dry bathtub in afternoon Ordered and ate 2 crabcakes and shrimp for dinner Became very upset when her friend/physician Dr. Eroshevich left town that evening
26	Timeline: Wednesday, Feb 7, Late Evening Complained of not feeling well and took a bath Seen on couch at 10:00 PM watching TV in the living room of the suite Howard K. Stern was in the bedroom in the suite
27	Timeline: Thursday, Feb 8 Took chloral hydrate before falling asleep in early morning No longer on couch at 4:00 AM About 9:00 AM - may have been seen moving in her bed by Maurice Brighthaupt (“Big Mo”)-friend/bodyguard/medic According to Howard K. Stern, he slept in bed with Miss Smith. When he woke up some time around 9-10:00 AM, she was awake. She did not complain of pain but felt very weak and asked Mr. Stern to help her to the bathroom and back to bed. Mr. Stern took a shower and left to attend to the purchase of a boat by Anna. Mr. Stern stated that he did not give Anna any medication and did not see Anna taking any medication At about 12:00 PM, Anna was seen “sleeping” by the wife of Big Mo, a registered nurse, who was asked to watch Anna by him About 1:00 PM the nurse called Big Mo to have him call 911 when Anna was found unresponsive The nurse initiated CPR
28	Timeline: Thursday, Feb 8 1:38 PM – Big Mo returned to room and continued CPR 1:40 PM - Seminole EMS called 1:46 PM - EMS arrived in hotel room, administered CPR and ACLS protocol (including medications such as atropine), and transported to hospital 2:43 PM - EMS arrived at Memorial Regional Hospital 2:49 PM - pronounced dead
29	Medical Examiner Timeline: Thursday, Feb 8 Body transported to Medical Examiner’s Office at 4:59 PM External examination and collecting of blood and body fluid samples for: bacteriological and viral cultures cerebrospinal fluid bacteriological cultures intestinal bacteriological and viral cultures DNA sampling Serum for toxicology and chemistries
30	Timeline: Friday, Feb 9 Autopsy performed at 10:36 AM Tissues and body fluids taken for microscopic examination and further toxicological, bacteriological, serological, and DNA analyses Initial assumptions (three choices): Natural death Drug/medication related death Combination of natural and drug related death Following interviews of witnesses (Dr. Eroshevich and Mr. Stern) we learned of the history of buttock pain and plans were made to re-examine and dissect this part of the body (not a routine procedure)
31	Initial Toxicology Findings Received 2/9/07 Urine drug screen: positive for benzodiazepines (anti-anxiety/anti-depressant medications) Blood and ocular (eye fluid) ethanol: negative Vitreous (eye fluid) glucose/electrolytes: non-specific chloride elevation; no evidence of hyperglycemia; inconsequential postmortem potassium elevation
32	Body Re-Examined 2/12/07 Incisions made into buttocks and thighs Abscesses noted within scar tissue in left buttock Extensive scarring of both buttocks Linear hemorrhages from skin to abscesses Microscopy: abscess, foreign material, and scarring in buttocks Cultures from abscesses grew bacteria: Pseudomonas luteola and Acinetobacter baumannii
33	Additional Toxicology Received week of 2/12/07 Blood drug screen positive for: Topiramate (Topamax; anti-seizure, weight control) Multiple benzodiazepines, including Valium (anti-anxiety), Klonopin (anticonvulsant) and Ativan (anti-anxiety) Meprobamate (anti-anxiety) Methocarbamol (muscle relaxant) Guaifenesin (phlegm expectorant) Diphenhydramine (anti-histamine) All of the above were at therapeutic levels
34	Additional Toxicology Drugs NOT present in the blood: Methadone cocaine amphetamines (“speed”) THC (marijuana) barbiturates (sleeping pills) morphine and other opiates other illicit drugs cyanide carbon monoxide succinylcholine (paralytic drug) All findings confirmed at independent referral labs
35	Rare Causes of Death Excluded Radiation poisoning (excluded by Geiger counter testing) Ricin and Anthrax poisoning (excluded by absence of microscopic changes) Thallium poisoning (excluded by symptoms, toxicology, & microscopic findings)
36	Evaluation for Sepsis Bacteria were isolated from buttocks abscesses (described above) These abscess bacteria were not present in blood, probably due to partial sensitivity to the antibiotic Cipro Terminal inhalation of oral cavity bacteria into lungs (but no vomit in airways or lungs) Blood, cerebrospinal fluid, urine cultures: no pathogenic organisms; mild growth of contaminants Elevated levels of interleukins 6 and 8 (pro-inflammatory agents) that indicate an acute inflammatory response, possibly infection No endotoxins detected
37	Additional Test Results Received Heavy metals: negative Insulin and C-peptide: within normal limits Cipro (ciprofloxacin) antibiotic level: therapeutic Human Growth Hormone: non-contributory Serum anti-nuclear antibodies: mildly elevated but double stranded DNA was negative Liver function tests: postmortem artifactual elevation of liver enzymes
38	Stool Cultures Negative for Salmonella, Shigella, Campylobacter, virulent E. Coli species Initial viral studies isolated Norwalk virus by screening assay A specific Norwalk virus could not be confirmed by PCR studies at referral lab or CDC
39	Possible Causes of Death as of 2/19/07 Sepsis due to deep soft tissue abscesses due to multiple cutaneous injections Viral enteritis Likely manner of death: Natural No significant contribution by therapeutic levels of medications Additional laboratory tests (microbiological, toxicological) still pending
40	Additional Test Results Received Immunoglobulins, complement C3, and serology: no evidence of immunodeficiency Special stains of spleen showed aberrant staining of B-lymphocytes (may be seen in some autoimmune states) Chloral hydrate blood level: markedly elevated (toxic to lethal level)
41	Chloral Hydrate Sedative/hypnotic drug used as sleeping medication Available as an elixir (liquid), capsules, suppositories Normal liquid dosage: 1-2 teaspoons before bed Total daily dosage should not exceed 2 grams (4 teaspoons) Side effects: confusion, hallucinations, diarrhea, nausea, stomach pain, and vomiting
42	Chloral Hydrate Toxicity Symptoms include extreme weakness, confusion, seizures, extreme drowsiness, low body temperature, staggering, changes in heart rate, and breathing problems Toxic blood levels: 20 to 240mg/L Fatalities reported at blood levels of: > 29mg/L Anna Nicole Smith’s blood level: 75mg/L May interact with diphenhydramine, anti-anxiety drugs, sedatives, tranquilizers, alcohol, narcotic pain relievers
43	Probable Cause of Death as of 3/2/07 Acute combined drug intoxication (chloral hydrate and therapeutic levels of other drugs) Contributory: Bacterial infection (abscesses) Mild viral enteritis (intestinal infection) Manner of death: ? Additional confirmatory testing and consultants reports pending
44	Week of March 5-9, 2007 Additional test results received: Non-contributory Consultants’ findings discussed: No surprises Interviews with involved parties concluded All data synthesized
45	Weeks of March 10-23 Follow-up on additional evidence with potential impact on manner of death Forensic examination of two computers confirmed intense grieving over Daniel’s death but showed that her mood had improved, she was generally enjoying life, and that she was planning on having another child Investigation completed Final reports generated
46	Final Cause of Death PRIMARY: Acute combined drug intoxication due to ingestion of multiple prescription medications CONTRIBUTORY: Bacterial infection (abscesses), Mild viral enteritis, “Flu” HOW INJURY OCCURRED: Ingested excessive chloral hydrate in combination with therapeutic levels of other medications
47	Manner of Death Determined by correlation of autopsy findings, adjunctive studies, and circumstances leading to death Alternatives: Homicide Suicide Accident Natural Undetermined
48	Determining Manner of Death in Cases of Drug Intoxication Personality traits Recent behavior Long term behavior including suicide attempts Habits of drug use & abuse Levels, types, and lethality of drugs in blood Ratio of parent drugs to breakdown products, (i.e., taking one massive dose or a little too much over time) Presence of pills or liquids in stomach Evidence of another individual administering drugs to a person (e.g., forced ingestion, assisted suicide)
49	Personality Traits of Anna Nicole Smith Strong personality Endured many difficult life experiences Solid business woman Could be domineering Tendency toward histrionic, attention-getting behavior Drug-seeking behavior and long history of prescription drug use including over self-medication Obsession with Marilyn Monroe (which was waning somewhat)
50	Possible Future Plans of Anna Nicole Smith Considering having another baby Considering marriage in late February 2007 Planning new business ventures Trip to Dubai in March
51	The Argument for Accident
52	The Argument for Accident
53	The Argument for Accident
54	The Argument for Accident
55	The Argument for Accident
56	The Argument for Accident
57	The Argument for Accident
58	The Argument for Accident
59	The Argument for Accident
60	The Argument for Accident
61
62	The Argument for Suicide
63	The Argument for Suicide
64	The Argument for Suicide
65	The Argument for Suicide
66	The Argument for Suicide
67	The Argument for Suicide
68	The Argument for Suicide
69	The Argument for Suicide
70	The Argument for Suicide
71	The Argument for Suicide
72
73	The Argument Against Homicide
74	The Argument Against Homicide
75	The Argument Against Homicide
76	The Argument Against Homicide
77	The Argument Against Homicide
78	The Argument Against Homicide
79	The Argument Against Homicide
80	The Argument Against Homicide
81	The Manner of Death Compelling arguments can be made for Accident Suicide is less likely Homicide is not supported by the police investigation or our findings Natural is not an option since death was caused by drug intoxication, not a natural disease process
82	Undetermined Manner of Death? The classification “Undetermined” is used when the information pointing to one manner of death is no more compelling than one or more other competing manners of death in thorough consideration of all available information.
83	The Manner of Death in this case is ACCIDENT. The evidence for Accident is more convincing than all other options (including suicide and homicide).
84	Conclusion