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Background Information Pertaining to the Forensic Investigation into the Death of Anna Nicole Smith. Joshua Perper, MD, LLB, MSc Chief Medical Examiner Broward County, Florida March 2007. Initial Information. Anna Nicole Smith found unresponsive at Seminole Hard Rock Hotel and Casino
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Joshua Perper, MD, LLB, MSc
Chief Medical Examiner
Broward County, Florida
Dr. Joshua PerperChief Medical Examiner
Dr. Stephen CinaDeputy Chief Medical Examiner
Dr. Gertrude JusteAssociate Medical Examiner
Dr. Reinhard MotteAssociate Medical Examiner
Dr. Harold SchuelerChief ToxicologistEdwina JohnsonChief InvestigatorWendy CraneInvestigator
Dean ReynoldsChief Autopsy Room Technician
Irma MotenAutopsy Room Technician
Joe AndersonVisual Imaging Technician
James FleurimondVisual Imaging Technician
* Changes visible to the naked eye
Dr. Stephen Nelson, neuropathologist and Chief Medical Examiner,Polk County, Florida
Dr. Michael Bell, cardiopathologist and Chief Medical Examiner,Palm Beach County, Florida
Dr. Azorides Morales, cardiopathologist and Chairman of Departmentof Pathology, University of Miami
Dr. Gordon Dickinson, infectious disease specialist, Professor and Chief of Department of Infectious Diseases, University of Miami
Dr. Margaret Gorensek, infectious disease specialist, Chief of Department of Infectious Diseases, Cleveland Clinic, Florida
Dr. Michael Bayerl, hematopathology, Assistant Professor, Department of Pathology, Milton S. Hershey Medical Center, Pennsylvania
In most cases of suicide, the victim ingests a large amount of a drug to ensure death. In this case, the toxic blood level of chloral hydrate could be fatal in and of itself but not necessarily so. However, it is definitely lethal in combination with other drugs which were present at therapeutic levels.
In many cases of prescription drug overdose, multiple drug levels are significantly elevated.In this case, all drugs except chloral hydrate were at therapeutic levels.
Reports of suicidal ideation were not substantiated after mid-October 2006.
Religious upbringing and ideology prohibit suicide.
A near drowning episode in a pool several months prior to death appears to have followed an accidental drug overdose rather than a suicidal act.
Indeed, she thanked the individual who had resuscitated her rather than being angry at him.
Miss Smith had a long history of prescription drug use and over-self medicating. She may have drank a little too much chloral hydrate to alleviate symptoms which were secondary to infection.
Miss Smith was likely not aware of the risks of using multiple drugs while in a physically vulnerable state consequent to her infections.
Miss Smith had just had a baby and, by some accounts, was often in good spirits. There was no evidence of depression on the way to Florida from the Bahamas or during her stay in Fort Lauderdale.
There was no suicide note (though these are absent in many suicides).
No statements expressing suicidal intent after mid-October 2006 were uncovered.
Suicidal ideation was absent in emails posted after mid-October 2006.
The investigation suggests she was making definitive plans for her immediate future.
Anna Nicole Smith was a very strong woman. Having survived the death of her son, it seems unlikely that she would choose to end her life because of her current legal problems.
Most close friends state that Miss Smith was devastated by the death of her son, Daniel, in September 2006.
She exhibited many symptoms of clinical depression.
Though it is unclear, Miss Smith may have threatened to kill herself after Daniel’s death, and possibly even attempted to do so by drowning in October 2006 (though this was more likely an accident).
Her depression over the loss of her son occurred shortly after the delivery of her infant daughter by Caesarean section.This is a very critical time in which many women are predisposed to endogenous depression, so-called postpartum depression.
Several months prior to her death,Miss Smith bought 4 plots in a Bahamian cemetery and had possibly commissioned a dress for her funeral.
There were several additional significant life stressors in play at the time of her death. She was involved in 4 lawsuits, the last of which was filed a week prior to her death.
By report, Miss Smith did not appear to be intoxicated when she was last seen alive. This suggests that she took a significant dose of chloral hydrate within a few hours of her death.
The ratio of chloral hydrate metabolites in the blood suggests ingestion of a significant quantity of the parent drug in the hours prior to death (though not minutes before death).
Miss Smith suffered from soft tissue abscesses and viral enteritis at the time of death. Some of the chemical mediators produced by the body in response to infection are also elevated in depression.
Miss Smith suffered from chronic pain and Hashimoto thyroiditis (chronic inflammation of the thyroid), both of which are associated with depression.
Miss Smith had stated a while ago that she wished to die in the same fashion as her idol, Marilyn Monroe, who died by suicide.Of note, Marilyn Monroe employed chloral hydrate (in combination with a barbiturate) in her highly publicized death.
Given the level of the chloral hydrate in Miss Smith’s blood, someone would have had to either force-fed her or have her voluntarily ingest a large amount of liquid chloral hydrate under duress.
Given the therapeutic levels of the other drugs in her system, Miss Smith may have been somewhat impaired but should have been capable of resisting attempts at forced feeding.
There was no oral trauma to suggest forced feeding.
Chloral hydrate has a very unpleasant, harsh taste which should be easily detectable if an attempt was made to “slip it” into a beverage.
There were no other significant injuries.
There is no evidence at present to suggest that another individual provided Miss Smith with drugs to actively assist her in taking her own life.
One could speculate that Miss Smith was cognitively impaired due to her infections and use of benzodiazepines and that this rendered her susceptible to homicidal poisoning. However this would represent mere speculation that is not supported by the evidence gathered during this investigation.
A police investigation was completed and found no evidence of foul play.
Hazlick et al. A Guide for Manner of Death Classification,1st Edition, National Association of Medical Examiners
The Manner of Death in this case is ACCIDENT.The evidence for Accident is more convincing than all other options (including suicide and homicide).
PRIMARY CAUSE OF DEATH:
Acute Combined Drug Intoxication (primarily chloral hydrate with other prescription medications) due to ingestion of multiple prescription medications
CONTRIBUTORY TO DEATH:Bacterial Infection (Abscesses), mild viral enteritis, “Flu”
MANNER OF DEATH: Accident
HOW INJURY OCCURRED:Ingested excessive chloral hydrate whiletaking multiple prescription medications