Jordan Carter - Autopsy - 2017-05939 - OD - Jail death

Central Office Investigator Colt Kalcich Field Investigator Donald Scott Medical Investigator Matthew Cain, MD Decedent last name: Decedent first name: Decedent middle: Decedent suffix: SSN: Birth date: Age: Gender: Race: Hispanic flag: Residence zip: Residence address: Residence county: Residence state: Reported by: Reported date: Reported by org: Identification by person name: ID method: ID type: Pronounced date: Pronounced by: Place of death: Hospital/hospice/nursing home: Where at facility/scene: Pronounced zip: CARTER JORDAN /1975 12:00:00 AM 42 Male White False 87004 1100 Montoya Road Sandoval NM sandoval regional dispatch 10/27/2017 1:30:00 AM Sandoval Co. SO Lt Schaefer Visual Positive 10/27/2017 2:15:00 AM don scott 1.92 Residence 87004 Pronounced addr: Pronounced city: Pronounced county: Pronounced state: 1100 Montoya Road Bernalillo Sandoval NM Residence city: Bernalillo ID relation: Law Enforcement GPS longitude: GPS latitude: Mortuary: Mortuary reported by: NOK name: UNK unk Arrival time: 10/27/2017 2:00:00 AM Report Name: Deputy Field Investigation Page 1 Printed: 10/22/2020 9:08:27 AM Case Number: 2017-05939 Deputy Field Investigation CARTER, JORDAN Relationship: NOK zip: NOK address: NOK city: NOK state: Phone1: Phone 2: Regular physician: Regular physician phone: Law enforcement agency: Agent in charge: Other investigating agency: Other agent: Field external: Exam location: Exam date: Exam time: JT: Death certificate signed by: Cause of death: Recent surgery: Surgery date: . NMSP Streater Sandoval SO Frank Thompson False False False Surgery description: Surgery date 2: Surgery 2 description: Pregnant? Pregnant: Pregnancy length: Date of injury: Date of injury unknown? Date of injury approx? Time of injury: Time of injury unknown? Time of injury approx? Injury at work: Injury zip: Injury place: Injury city: Injury county: Injury state: Death circumstances: False 10/27/2017 12:00:00 AM False False 10/27/2017 12:00:00 AM False True UNK Sandoval Jail 1100 montoya Report Name: Deputy Field Investigation Page 2 Printed: 10/22/2020 9:08:27 AM Case Number: 2017-05939 Deputy Field Investigation CARTER, JORDAN Describe scene: Describe decedent: Past medical history: The decedent reportedly (per jail mate) was talking and suddenly had what he though was a ""seizure" and "hit his head on the bunk" . His jail mate then threw a full glass of water on him to "wake him up". The jail mate them began banging on the window for help which lead to correctional officers to respond to the cell. The decedent found him decreased conscious. He was on his top bunk bed. NMSP were called and then OMI. The decedent was a Federal Prisoner housed at the Sandoval Jail sense 2016. He was currently in jail pod 1 -A2 There were 2 people per cell. He occupied the top bunk. The cell was in order and staff had not found in controband in the cell. The decedent was lying supine , in orange prison pants and shoes, tee shirt. No trauma was found. Livor was posterior to his back non fixed with rigor non fixed. Comments: At time of report no next of Kin were known. Jail was attempting to locate. Clothing and valuables: Medications located at: Medications turned over to: Medications turned over date: Medications turned over by: Medications counting witness by: Medications log: CODMI consulted: CODMI instructions: One way mileage: 12 Report Name: Deputy Field Investigation Page 3 Printed: 10/22/2020 9:08:27 AM Case Number: 2017-05939 Deputy Field Investigation CARTER, JORDAN CAUSE OF DEATH Toxic effects of Fentanyl and Acetyl fentanyl MANNER OF DEATH Accident DEATH INVESTIGATION SUMMARY Case Number: 2017-05939 CARTER, JORDAN Matthew Cain, MD Medical Investigator, Assistant Professor of Pathology Mark Giffen, DO Forensic Pathology Fellow All signatures authenticated electronically Date: 12/18/2017 12:48:00 PM County Pronounced: Sandoval Law Enforcement: NMSP Agent: Streater Date of Birth: /1975 Central Office Investigator: Colt Kalcich Deputy Field Investigator: Scott, Don Pronounced Date/Time: 10/27/2017 2:15:00 AM Printed: 10/22/2020 9:03:10 AM Report Name: Death Investigation Reporting Tool Death Investigation Report page 1 of 23 DECLARATION The death of CARTER, JORDAN was investigated by the Office of the Medical Investigator under the statutory authority of the Office of the Medical Investigator. I, Matthew Cain, MD, a board certified anatomic, clinical, and forensic licensed to practice pathology in the State of New Mexico, do declare that I personally performed or supervised the tasks described within this Death Investigation Summary document. It is only after careful consideration of all data available to me at the time that this report was finalized that I attest to the diagnoses and opinions stated herein. Numerous photographs were obtained along the course of the examination. I have personally reviewed those photographs and attest that they are representative of findings reported in this document. This document is divided into 8 sections with a final Procedural Notes section: 1. Summary and Opinion 2. External Examination 3. Medical Intervention 4. Postmortem Changes 5. Evidence of Injuries 6. Internal Examination 7. Microscopy 8. Postmortem Computed Tomography Should you have questions after review of this material, please feel free to contact me at the Office of the Medical Investigator (Albuquerque, New Mexico) - 505-272-3053. Printed: 10/22/2020 9:03:12 AM Report Name: Death Investigation Summary Death Investigation Report page 2 of 23 Medical Investigator Matthew Cain, MD Medical lnvestigator Trainee Mark Giffen, DO PATHOLOGIC DIAGNOSES: I. Toxic effects of fentanyl and acetyl fentanyl A. Postmortem femoral blood fentanyl; 9.1 ng/mL 1. Postmortem femoral blood norfentanyl; 1.6 ng/mL B. Postmortem femoral blood acetyl fentanyl; 1.4 ng/mL C. Moderate cerebral edema D. Mild pulmonary edema II. Hypertensive cardiovascular disease A. Mild left ventricular hypertrophy B. Renal glomerulosclerosis, mild III. Bilateral renal calcifications IV. Mitral valve prolapse (per medical history) V. Asthma (per medical history) SUMMARY AND OPINION: Mr. Jordan Carter was a 42 year old man . He was reportedly in an altercation in early September with an orbital fracture but had recovered without significant difficulties. According to investigative reports, Mr. Carter was incarcerated and his cellmate reports that he suddenly became unresponsive and had seizure like activity. He was suspected to have used intravenous drugs, though no paraphrenalia was found in his cell. Findings at autopsy included moderate cerebral edema (brain swelling) and mild pulmonary edema (fluid in the lungs). Also present were mild thickening of the left ventricle of the heart and mild scarring of the kidneys with calcifications. Postmortem computed tomography demonstrated no additional findings. Testing of postmortem blood samples for alcohol and common drugs of abuse revealed lethal levels of fentanyl and acetyl fentanyl with the metabolite norfentanyl also present. Fentanyl and acetyl fentanyl are both potent synthetic opioid drugs with central nervous system depressant activity which can decrease consciousness and result in death by preventing breathing. Also identified in the toxicology screen were therapeutic levels of the prescribed medications, sertraline and it's metabolite, desmethylsertraline, amitriptyline and it's metabolite nortriptyline, and gabapentin. Caffeine was also detected but not measured. It is our opinion, based on the circumstances surrounding death and the autopsy findings, that Mr. Jordan Carter died of toxic effects of fentanyl and acetyl fentanyl. The manner of death is accident. SUMMARY AND OPINION Cause Of Death: Page 1 Printed: 10/22/2020 9:03:12 AM Case Number: 2017-05939 Summary Opinion CARTER, JORDAN Death Investigation Report page 3 of 23 Medical Investigator Matthew Cain, MD Authority for examination: Body length (cm): Body weight (kgs): BMI: Development: Stature: Age: Anasarca: Edema localized: Dehydration: Scalp hair color: Scalp hair length: Eyes: OMI 176.00 86.20 27.83 Well-developed Well-nourished Appears to be stated age No No No Brown Short Both eyes present Irides: Eyes corneae: Eyes sclerae: Brown Translucent White Eyes conjunctivae: Eyes petechiae: Palpebral petechiae: Bulbar petechiae: Facial petechiae: Oral mucosal petechiae: Nose: Translucent No No No No No Normally formed External exam date time: 10/27/2017 9:18:00 AM Medical Investigator Trainee Mark Giffen, DO Means used to confirm identity: Other verification means: Location of orange bracelet: Name on orange bracelet: Other name on orange bracelet: Location of green bracelet: Name on green bracelet: Other name on green bracelet: Hospital ID tags or bracelets? If yes specify stated name and location: Visual Left wrist Decedent name Left wrist Decedent name No ID confirmed at time of exam: Yes Development comments: External Examination Page 1 Printed: 10/22/2020 9:03:13 AM Case Number: 2017-05939 External Examination CARTER, JORDAN Death Investigation Report page 4 of 23 Ears: Lips: Facial hair: Facial hair color: Maxillary dentition: Mandibular dentition: Condition of dentition: Neck: Trachea midline: Normally formed Normally formed Stubble in the pattern of a beard and moustache Brown Natural Natural Good Unremarkable Yes Chest symmetrical: Chest diameter: Abdomen: Back: Spine: External genitalia: Breast masses: Right hand digits complete: Left hand digits complete: Right foot digits complete: Yes Appropriate Flat Unremarkable Normal Male None Yes Yes Yes Breast development: None Chest development: Left foot digits complete: Yes Muscle group atrophy: Senile purpura: Pitting edema: No No No Muscle other: No Tattoo(s) Tattoos present: Yes Tattoo anterior neck: Yes Tattoo right lateral neck: Yes Tattoo left lateral neck: Yes Tattoo posterior neck: Yes Tattoo anterior chest: Yes Tattoo right shoulder: Yes Tattoo right arm: Yes Tattoo left shoulder: Yes Tattoo left arm: Yes Tattoo left forearm: Yes Extremities: Well-developed and symmetrical Normal Anus: Unremarkable External Examination Page 2 Printed: 10/22/2020 9:03:13 AM Case Number: 2017-05939 External Examination CARTER, JORDAN Death Investigation Report page 5 of 23 Tattoo left ankle: Yes Cosmetic Piercing(s) Cosmetic piercing present: No Scar(s) Scar(s) present: No Reported by: Mark Giffen, DO Verified by: Matthew Cain, MD on 12/18/2017 12:39:19 PM Reviewed and approved by: Matthew Cain, MD on 12/18/2017 12:48:12 PM Reporting Tracking External Examination Page 3 Printed: 10/22/2020 9:03:13 AM Case Number: 2017-05939 External Examination CARTER, JORDAN Death Investigation Report page 6 of 23 Case Number: 2017-05939 Medical Investigator Matthew Cain, MD Evidence of medical intervention: If nasogastric tube present, specify course and position: If endotracheal tube present, specify course and position: Endotracheal tube: Endotracheal tube comment: Tracheostomy site/tube: Mediastinal tube(s): Chest tube(s): If Foley catheter present, specify course and position: ECG Monitoring Pads Present?: ECG abdomen pads: ECG shins pads: Other pads comments: Defibrillator pads present?: Right upper outer chest: Left Lower outer chest: Other pads comments: D efib pads x 4 Vascular catheter(s): lntraosseous - proximal left shin: Evidence of recent surgical intervention: Reported by: Verified by: Reviewed and approved by: Medical Intervention Medical Intervention Medical Investigator Trainee Mark Giffen, DO • Indwelling Tubes • • - • • • • Electrocardiogram (ECG) Monitoring Pads • • • Defibrillator Pads • • • Vascular Catheter(s): • • Recent Surgical Intervention • Report Tracking Mark Giffen, DO Matthew Cain, MD on 12/18/2017 12:33:55 PM Matthew Cain, MD on 12/18/2017 12:48: 12 PM Page 1 Death Investigation Report page 7 of 23 CARTER, JORDAN Printed: 10/22/2020 9:03:13 AM Medical Investigator Matthew Cain, MD Body temperature: Rigor mortis: Livor mortis - color: Livor mortis - fixation (if applicable): Livor mortis - position (if applicable): State of preservation: Cool subsequent to refrigeration Partially fixed Purple Partially fixed Posterior No decomposition External exam date: 10/27/2017 9:18:00 AM Medical Investigator Trainee Mark Giffen, DO Reported by: Mark Giffen, DO Verified by: Matthew Cain, MD on 12/18/2017 12:38:23 PM Reviewed and approved by: Matthew Cain, MD on 12/18/2017 12:48:12 PM Report Tracking Postmortem Changes Page 1 Printed: 10/22/2020 9:03:13 AM Case Number: 2017-05939 Postmortem Changes CARTER, JORDAN Death Investigation Report page 8 of 23 Medical Investigator Matthew Cain, MD Autopsy date: 10/27/2017 9:15:00 AM Evidence of Injury: Medical lnvestigator Trainee Mark Giffen, DO # Injury Location Injury Description Are there any injuries: No Reported by: Mark Giffen, DO Verified by: Matthew Cain, MD on 12/18/2017 12:41:04 PM Reviewed and approved by: Matthew Cain, MD on 12/18/2017 12:48:12 PM Report Tracking Evidence of Injury Page 1 Printed: 10/22/2020 9:03:14 AM Case Number: 2017-05939 Evidence of Injury CARTER, JORDAN Death Investigation Report page 9 of 23 Medical Investigator Matthew Cain, MD Date of Internal Exam: Chest cavities examined: See evidence of injury section Organs in normal anatomic position Other organ position comments Diaphragm: Serosal surfaces: Body cavity adhesions present: Fluid accumulation present: Brain examined: See separate forensic neuropathology consultation report See evidence of injury section: See evidence of medical Intervention section: 10/27/2017 9:18:00 AM Yes No Yes Intact Smooth and glistening No No Yes No No No See postmortem changes section: Facial skeleton: Calvarium: Skull base: No No palpable fractures No fractures No fractures Dura mater: Skull comments: Dural venous sinsuses: Leptomeninges: Epidural hemorrhages / hematomas: Subdural hemorrhages / hematomas: Subarachnoid hemorrhages: Cerebral hemispheres: Gyral and sulcal patterns: Gyral convolutions and sulci: Uncal processes: Cerebellar tonsils: Unremarkable and without masses Patent Thin and transparent Absent Absent Absent Symmetrical Unremarkable Moderate widening and flattening of sulci and moderate narrowing of sulci Unremarkable Unremarkable Date of Autopsy: 10/27/2017 9:15:00 AM Medical lnvestigator Trainee Mark Giffen, DO BODY CAVITIES HEAD Brain fresh (g): Brain fixed (g): 1605 Internal Examination Page 1 Printed: 10/22/2020 9:03:16 AM Case Number: 2017-05939 Internal Examination CARTER, JORDAN Death Investigation Report page 10 of 23 Spinal cord examined: Middle ears examined: No No Cranial nerves: Basilar arterial vasculature: Cerebral cortex: White matter: Corpus callosum: Deep gray matter structures: Brainstem: Cerebellum: Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable Neck examined: See Evidence of Injury section: See Evidence of Medical Intervention section See Postmortem Changes section: Subcutaneous soft tissues: Strap muscles: Jugular veins: Carotid arteries: Tongue: Epiglottis: Hyoid bone: Larynx: Palatine tonsils: Yes No No No Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable Not examined Spinal Cord Middle Ears Neck CARDIOVASCULAR SYSTEM See separate Cardiovascular Pathology report: See Evidence of Injury section: See Evidence of Medical Intervention section: See Postmortem Changes section: Right coronary ostium position: Left coronary ostium position: Supply of the posterior myocardium: Right coronary ostium: No No No No Normal Normal Right coronary artery 0 Heart examined: Yes Heart Coronary artery stenosis by atherosclerosis (in percent): Heart fixed (g): Heart fresh (g): 330.0 Internal Examination Page 2 Printed: 10/22/2020 9:03:16 AM Case Number: 2017-05939 Internal Examination CARTER, JORDAN Death Investigation Report page 11 of 23 Great vessels examined: Aorta examined: Proximal third right coronary artery: Middle third right coronary artery: Left coronary ostium: Left main coronary artery: Proximal third left anterior descending coronary artery: Middle third left anterior descending coronary artery: Distal third left anterior descending coronary artery: Proximal third left circumflex coronary artery: Distal third left circumflex coronary artery: Cardiac chambers: Tricuspid valve: Pulmonic valve: Mitral valve: Aortic valve: Yes Yes 0 0 0 0 0 0 0 0 0 Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable Right ventricular myocardium: Left ventricular myocardium: No fibrosis, erythema, pathologic infiltration of adipose tissue or areas of accentuated softening or induration No fibrosis, erythema, or areas of accentuated softening or induration Distal third right coronary artery: 0 Middle third left circumflex coronary artery: 0 Ventricular septum: Right ventricular free wall thickness: Left ventricular free wall thickness: Interventricular septum thickness: Orifices of the major vascular branches: Coarctation: Vascular dissection: Aneurysm formation: Complex atherosclerosis: Other aortic pathology: Vena cava and major tributaries: Unremarkable 0.3 cm 1.2 cm 0.9 cm Patent No No No No No Patent Atrial septum: Unremarkable Aorta Vena Cava Cardiac Chambers and Valves: Internal Examination Page 3 Printed: 10/22/2020 9:03:16 AM Case Number: 2017-05939 Internal Examination CARTER, JORDAN Death Investigation Report page 12 of 23 Lungs examined: See separate Cardiovascular Pathology report: See Evidence of Medical Intervention section: See Evidence of Injury section: Upper and lower airways: Pulmonary parenchyma color: Pulmonary parenchyma congestion and edema: Pulmonary trunk: Pulmonary artery thrombi: Yes No No No Unobstructed, and the mucosal surfaces are smooth and yellow-tan Dark red-purple Slight amounts of blood and frothy fluid Free of saddle embolus None See Postmortem Changes section: No RESPIRATORY SYSTEM Liver examined: See Evidence of Injury section: See Evidence of Medical Intervention section: See Postmortem Changes section: Hepatic parenchyma (color): Hepatic parenchyma (texture): Hepatic vasculature: Gallbladder: Gallstones: Intrahepatic biliary tree: Extrahepatic biliary tree: Alimentary tract examined: See Evidence of Injury section: See Evidence of Medical Intervention section: See Postmortem Changes section: Yes No No No Red-brown Unremarkable Unremarkable and free of thrombus Unremarkable None Unremarkable Unremarkable Yes No No No Pulmonary artery atherosclerosis: None HEPATOBILIARY SYSTEM GASTROINTESTINAL SYSTEM Lung right (g): Lung left (g): Liver (g): Stomach contents vol (mL): 540 470 1770 450 Bile vol (mL): Gallstones autopsy: Gallstones autopsy desc: Appendix found: 10 No Yes Stomach contents description: Thin brown fluid and food particulates Internal Examination Page 4 Printed: 10/22/2020 9:03:16 AM Case Number: 2017-05939 Internal Examination CARTER, JORDAN Death Investigation Report page 13 of 23 Course: Mucosa: Mucosa: Pylorus: Luminal contents: Normal course without fistulae Gray-white, smooth and without lesions Usual rugal folds Patent and without muscular hypertrophy Partially digested food Esophagus Stomach Colon Pancreas Small Intestine Caliber and continuity: Luminal contents: Mucosa: Caliber and continuity: Form: Genitourinary system examined: See Evidence of Injury section: See Evidence of Medical Intervention section: See Postmortem Changes section: Cortical surfaces: Cortices: Calyces, pelves and ureters: Urinary bladder mucosa: Location: Size: Consistency: Other testicle comments: Size: Appropriate caliber without interruption of luminal continuity Formed stool Unremarkable Appropriate caliber without interruption of luminal continuity Normal tan, lobulated appearance Yes No No No Slightly granular Normal thickness and well-delineated from the medullary pyramids Non-dilated and free of stones and masses Gray-tan and smooth Bilaterally intrascrotal Unremarkable Homogeneous Unremarkable Kidneys capsules: Thin, semitransparent Male: Yes Mucosa: Unremarkable GENITOURINARY SYSTEM Kidneys Urinary Bladder Male Testicles Prostate Gland Kidney right (g): 130 Kidney left (g): 125 Urine volume (mL): Urine description: 15 yellow Internal Examination Page 5 Printed: 10/22/2020 9:03:16 AM Case Number: 2017-05939 Internal Examination CARTER, JORDAN Death Investigation Report page 14 of 23 Other prostate gland comments: Spleen (g): Adrenal right (g): Adrenal left (g): Thymus (g): 225 25 25 0 Consistency: Homogeneous Reticuloendothelial system examined: See Evidence of Injury section: See Postmortem Changes section: Color: Regional adenopathy: Yes No No Red-brown, homogeneous and ample No adenopathy See Evidence of Medical Intervention section: No RETICULOENDOTHELIAL SYSTEM Spleen Bone Marrow Lymph Nodes Endocrine system examined: See Evidence of Injury section: See Evidence of Medical Intervention section: See Postmortem Changes section: Size: Position: Size: Parenchyma: Size: Musculoskeletal system examined: See Evidence of Injury section: See Evidence of Medical Intervention section: Yes No No No Normal Normal Normal Homogeneous Normal Yes No No Parenchyma: Yellow cortices and gray medullae with the expected corticomedullary ratio Parenchyma: Absent (involution by adipose tissue) Thymus ENDOCRINE SYSTEM Pituitary Gland Thyroid Gland MUSCULOSKELETAL SYSTEM Adrenal Glands Spleen parenchyma: Moderately firm Spleen capsule: Intact Spleen white pulp: Prominent Internal Examination Page 6 Printed: 10/22/2020 9:03:16 AM Case Number: 2017-05939 Internal Examination CARTER, JORDAN Death Investigation Report page 15 of 23 See Postmortem Changes section: Bony framework: Subcutaneous soft tissues: No Unremarkable Unremarkable Musculature: Unremarkable ADDITIONAL COMMENTS Reported by: Mark Giffen, DO Verified by: Matthew Cain, MD on 12/18/2017 12:33:48 PM Reviewed and approved by: Matthew Cain, MD on 12/18/2017 12:48:12 PM Report Tracking Internal Examination Page 7 Printed: 10/22/2020 9:03:16 AM Case Number: 2017-05939 Internal Examination CARTER, JORDAN Death Investigation Report page 16 of 23 Medical Investigator Matthew Cain, MD Microscopic description: Microscopic Description: The liver is organized into plates of hepatocytes 1-2 cell layers thick without steatosis or inflammation. The portal tracts contain an appropriate number of blood vessels and bile ducts. The hepatic sinusoids are mildly dilated. No significant fibrosis, steatosis or inflammation is present. The pancreas has well formed acinar structures and islets without atypia. No significant inflammation or fibrosis are present. The left kidney has rare globally sclerotic glomeruli without significant inflammation. The proximal and distal tubules have moderate autolytic changes with tubular drop out and resultant interstitial fibrosis. No significant inflammation is present within the tubules or interstitium. Calcifications are present within multiple tubules. No polarizable material is present. The heart has no significant inflammation or fibrosis. The cardiac myocytes are unremarkable. The myocardial vessels are patent without significant medial hypertrophy or thrombosis. The lungs have normal alveolar architecture with focal marked edema and scattered extravasated intra-alveolar erythrocytes. The interstitium has no significant fibrosis or inflammation. Within the edematous fluid are rounded polarizable crystals. The left cerebellum contains mild hypoxic ischemic changes of the purkinje cells without gliosis or inflammation. Medical lnvestigator Trainee Mark Giffen, DO Block Tissue Location Description Stain A1 Liver, Pancreas and Left Kidney A2 Left ventricle, Right ventricle and Interventricular septum A3 Upper lobe of left lung and Lower lobe of right lung A4 Left cerebellum *Unless otherwise indicated sections are stained only with hematoxylin and eosin (H&E). Reported by: Mark Giffen, DO Verified by: Matthew Cain, MD on 12/18/2017 12:37:57 PM Reviewed and approved by: Matthew Cain, MD on 12/18/2017 12:48:12 PM Report Tracking Microscopy: Page 1 Printed: 10/22/2020 9:03:16 AM Case Number: 2017-05939 Microscopy CARTER, JORDAN Death Investigation Report page 17 of 23 Case Number: 2017-05939 Medical Investigator Matthew Cain, MD Date of examination: Study date: Accession number: Exam type: Technique: Comparison: Comments: PMCT 10/27/20179:15:00 AM 10/27/2017 7:54:00 AM Postmortem Full Body Computed Tomography Standard None CARTER, JORDAN Postmo1tem computed tomography (CT) images have been reviewed and inte1preted by the forensic pathologist. Postmo1tem CT findings: There is mild cerebral edema. The lungs have patchy ground glass opacities. The bilateral kidneys have multiple puncta.te calcifications. No traumatic injuries or significant natural disease are present. Reported by: Verified by: Reviewed and approved by: Computed Tomography Report Tracking Mark Giffen, DO Matthew Cain, MD on 12/ 18/2017 12:38:45 PM Matthew Cain, MD on 12/ 18/2017 12:48:12 PM Page 1 Death Investigation Report page 18 of 23 Printed: 10/22/2020 9:03:17 AM Yellow Sheet Morphology Technician Evidence Jordan Sousa Evidence Jordan Sousa Radiology Jordan Sousa Retention Jordan Sousa LabOther Jordan Sousa Attendees Jordan Sousa Identification Jordan Sousa Autopsy Jordan Sousa Case Number: Date of Examination: Pathologist: Fellow/Resident: 2017-05939 10/27/2017 9:15:00 AM Matthew Cain, MD Mark Giffen, DO Decedent Name: CARTER, JORDAN Morphology technican(s) present Morphology technican supervisor(s) present Yellow Sheet Morphology Technician Lead Identification Micaela Aragon-Greer Autopsy Cassandra Toledo Evidence Sharon Howard Radiology Sharon Howard Retention Sharon Howard LabOther Amanda Douglas Attendees Sharon Howard Procedural Notes Report Page 1 Printed: 10/22/2020 9:03:18 AM Case Number: 2017-05939 Procedural Notes CARTER, JORDAN Death Investigation Report page 19 of 23 Autopsy attendees Other morphology technicians present: Lilie Pham- Student Technician Procedural Notes Report Page 2 Printed: 10/22/2020 9:03:18 AM Case Number: 2017-05939 Procedural Notes CARTER, JORDAN Death Investigation Report page 20 of 23 Specimens obtained for laboratory testing Approach to autopsy dissection HIV serology: No HCV/HBV serology : Influenza serology: Other serology: Freezer protocol: DNA card: Metabolic screen: Cytogenetics: Med-X protocol: Urine dipstick: Blood cultures (bacterial): Lung cultures (bacterial): CSF culture (bacterial): Spleen culture (bacterial): Stool culture (bacterial): Other bacterial culture (specify): Mycobacterial culture (lung): Mycobacterial culture (other): No No No No Yes No No No No No No No No No No No Rokitansky evisceration: No Virchow evisceration: Yes Modified evisceration: No Viral Cultures: No HIV spin and store: Yes Procedural Notes Report Page 3 Printed: 10/22/2020 9:03:18 AM Case Number: 2017-05939 Procedural Notes CARTER, JORDAN Death Investigation Report page 21 of 23 Special autopsy techniques Tissues retention Disposition of tissues retained for extended examination Pericranial membrane removal: No Neck anterior dissection: No Neck posterior dissection: No Facial dissection: No Vertebral artery dissection (in situ): No Cervical spine removal: No Layered anterior trunk dissection: No Anterolateral rib arc dissection: No Back dissection: No Posterior rib arc dissection: No Extremity soft tissue dissection: No Eye enucleation: No Inner middle ear evaluation: No Maxilla or mandible resection: No Spinal cord removal (anterior): No Spinal cord removal (posterior): No Other dissection(s): Stock jar with standard tissue retention: Yes Rib segment: Yes Pituitary gland: Yes Breast tissue (women only): No Brain retention: No Spinal cord retention: No Cervical spine retention: No Heart retention: No Heart-lung block retention: No Rib cage retention: No Long bone retention: No Other retention,specify: Specimen outcome: Not applicable; no tissues were retained for extended examination. HIV serology: No Procedural Notes Report Page 4 Printed: 10/22/2020 9:03:18 AM Case Number: 2017-05939 Procedural Notes CARTER, JORDAN Death Investigation Report page 22 of 23 Number of scene photos produced by the OMI Number of autopsy photos produced by the OMI Evidence collected Personal effects Clothing Scene Photos: 0 Autopsy Photos: 11 FBI blood tube: No Blood spot card: No APD blood card: No Thumbprint: Yes Fingerprints: Yes Palmprints: No Print hold: No Oral swab: No Vaginal swab: No Anal swab: No Other swab: No Fingernails: No Scalp hair: No Pubic hair: No Pubic hair combing: No Projectile(s): No Retain clothing: No Retain valuables: No Retain trace evidence: No Retain body bag: No Retain hand bags: No Ligature: No Other evidence retained: Property Type Property Description Property Detail Fingerprints Describe One set Property Type Property Description Property Detail Clothing Shirt n/a Clothing Pants n/a Clothing Underpants n/a Clothing Socks n/a Procedural Notes Report Page 5 Printed: 10/22/2020 9:03:18 AM Case Number: 2017-05939 Procedural Notes CARTER, JORDAN Death Investigation Report page 23 of 23 NMS Labs 3701 Welsh Road, PO Box 433A, Willow Grove, PA 19090-0437 Phone: (215) 657-4900 Fax: (215) 657-2972 e-mail: nms@nmslabs.com Robert A. Middleberg, PhD, F-ABFT, DABCC-TC, Laboratory Director CONFIDENTIAL Toxicology Report Report Issued 11/14/2017 21:00 20141 New Mexico Office of Medical Investigators Attn: Yvonne A. Villalobos 1101 Camino de Salud NE- Ste B Albuquerque, NM 87105 To: Patient Name Patient ID Chain Age Gender Workorder Carter Jordan 2017-05939 85116 42 Y Male 17337840 DOB /1975 Positive Findings: Compound Result Units Matrix Source Gabapentin 9.5 mcg/mL 001 - Femoral Blood Caffeine Positive mcg/mL 001 - Femoral Blood Sertraline 88 ng/mL 001 - Femoral Blood Desmethylsertraline 370 ng/mL 001 - Femoral Blood Acetyl Fentanyl 1.3 ng/mL 001 - Femoral Blood Amitriptyline 300 ng/mL 001 - Femoral Blood Nortriptyline 150 ng/mL 001 - Femoral Blood Fentanyl 9.1 ng/mL 001 - Femoral Blood Norfentanyl 1.6 ng/mL 001 - Femoral Blood Acetyl Fentanyl 1.4 ng/mL 001 - Femoral Blood Fentanyl / Metabolite Presump Pos ng/mL 003 - Postmortem Urine See Detailed Findings section for additional information Testing Requested: Analysis Code Description 8063B Postmortem, Basic to Expanded Upgrade, Blood (Forensic) 8050U Postmortem, Urine Screen Add-on (6-MAM Quantification only) 2143B Gabapentin, Blood 8051B Postmortem, Basic, Blood (Forensic) Specimens Received: ID Tube/Container Volume/ Mass Collection Date/Time Matrix Source Miscellaneous Information 001 Gray Top Tube 9 mL 10/27/2017 Femoral Blood 002 Gray Top Tube 8 mL 10/27/2017 Femoral Blood 003 White Plastic Container 15 mL 10/27/2017 Postmortem Urine All sample volumes/weights are approximations. Specimens received on 10/31/2017. NMS v.18.0 Page 1 of 6 Detailed Findings: Analysis and Comments Result Units Rpt. Limit Specimen Source Analysis By Gabapentin 9.5 1.0 001 - Femoral Blood LC-MS/MS Caffeine Positive 0.20 001 - Femoral Blood LC/TOF-MS Sertraline 88 10 001 - Femoral Blood LC-MS/MS Desmethylsertraline 370 20 001 - Femoral Blood LC-MS/MS Acetyl Fentanyl 1.3 0.10 001 - Femoral Blood LC-MS/MS Amitriptyline 300 20 001 - Femoral Blood GC Nortriptyline 150 20 001 - Femoral Blood GC Fentanyl 9.1 0.10 001 - Femoral Blood LC-MS/MS Norfentanyl 1.6 0.20 001 - Femoral Blood LC-MS/MS Acetyl Fentanyl 1.4 0.10 001 - Femoral Blood LC-MS/MS Fentanyl / Metabolite Presump Pos 2.0 003 - Postmortem Urine EIA This test is an unconfirmed screen. Confirmation by a more definitive technique such as GC/MS is recommended. Other than the above findings, examination of the specimen(s) submitted did not reveal any positive findings of toxicological significance by procedures outlined in the accompanying Analysis Summary. Reference Comments: Acetyl Fentanyl - Femoral Blood: Acetyl fentanyl is a novel non-prescription synthetic opioid that has been implicated in several deaths. This fentanyl analog was previously undocumented in illicit drug use and is estimated to be five times more potent than heroin. Several state agencies have issued public health warnings. The Centers for Disease Control (CDC) has recommended increased vigilance by public health agencies, emergency departments, state laboratories, medical examiners, and coroners for patients with symptoms consistent with opioid overdose. It is also recommended that if a fentanyl immunoassay (e.g., ELISA) produces a positive result additional confirmation testing be performed and that this testing should include fentanyl and its analogs, including acetyl fentanyl. 1. Amitriptyline (Elavil®; Endep®) - Femoral Blood: Amitriptyline is a tricyclic compound used in the treatment of depression. The compound undergoes extensive metabolism, and its major metabolite, nortriptyline, is also active as an antidepressant. Optimal patient response is usually observed when plasma concentrations of amitriptyline plus nortriptyline range from 80 - 200 ng/mL. A reported range of amitriptyline blood concentrations in fatalities from ingestion of amitriptyline range from 3000 - 15000 ng/mL. Post-mortem blood concentrations of tricyclic antidepressants and structurally-related compounds may depend on the anatomic source of the blood specimen. Concentrations may be higher in blood from visceral organs and the major vessels associated with them than actual ante-mortem circulating levels. 2. Caffeine (No-Doz) - Femoral Blood: Caffeine is a xanthine-derived central nervous system stimulant. It also produces diuresis and cardiac and respiratory stimulation. It can be readily found in such items as coffee, tea, soft drinks and chocolate. As a reference, a typical cup of coffee or tea contains between 40 to 100 mg caffeine. The reported qualitative result for this substance was based upon a single analysis only. If confirmation testing is required please contact the laboratory. 3. NMS v.18.0 CONFIDENTIAL Workorder Chain Patient ID 17337840 85116 2017-05939 Page 2 of 6 Reference Comments: Desmethylsertraline (Norsertraline; Sertraline Metabolite) - Femoral Blood: Desmethylsertraline is the principal metabolite of sertraline and has about 10 to 20% of the pharmacologic activity of the parent compound. Fifteen adults taking 200 mg daily sertraline had mean trough serum concentrations of 87 ng/mL desmethylsertraline (range 40 - 189 ng/mL). In a report of seven postmortem cases in which sertraline was not related to the cause of death, desmethylsertraline concentrations were 80 - 990 ng/mL in heart blood. A patient survived an acute overdose with a serum concentration of 1700 ng/mL desmethylsertraline. Her symptoms included confusion, agitation, fever and seizures. 4. Fentanyl (Duragesic®; Sublimaze®) - Femoral Blood: Fentanyl is a DEA Schedule II synthetic morphine substitute anesthetic/analgesic. It is reported to be 80 to 200 times as potent as morphine and has a rapid onset of action as well as addictive properties. It is reported that patients lost consciousness at mean plasma levels of fentanyl of 34 ng/mL when infused with 75 mcg/Kg over a 15 min period; peak plasma levels averaged 50 ng/mL. After application of a fentanyl transdermal preparation (patch), serum fentanyl concentrations are reported to be in the following ranges within 24 hours: 25 mcg/hour patch: 0.3 - 1.2 ng/mL 50 mcg/hour patch: 0.6 - 1.8 ng/mL 75 mcg/hour patch: 1.1 - 2.6 ng/mL 100 mcg/hour patch: 1.9 - 3.8 ng/mL Following removal of the patch, serum fentanyl concentrations are reported to decrease with a mean elimination half-life of 17 hours (range, 13 to 22 hours). The mean peak plasma serum fentanyl concentration in adults given an 800 mcg oral transmucosal fentanyl preparation over 15 minutes is reported at 2.1 ng/mL (range, 1.4 - 3.0 ng/mL) at approximately 0.4 hours. Signs associated with fentanyl toxicity include severe respiratory depression, seizures, hypotension, coma and death. In fatalities from fentanyl, blood concentrations are variable and have been reported as low as 3 ng/mL. Substance(s) known to interfere with the identity and/or quantity of the reported result: 4-methylphenethyl acetyl fentanyl 5. Fentanyl / Metabolite - Postmortem Urine: Fentanyl is a DEA Schedule II synthetic morphine substitute anesthetic/analgesic. It is reported to be 80 to 200 times as potent as morphine and has a rapid onset of action as well as addictive properties. This result derives from a presumptive test, which may be subject to cross-reactivity with non-fentanyl related compounds. A second test is necessary to confirm the presence of fentanyl related compounds. 6. Gabapentin (Neurontin®) - Femoral Blood: Gabapentin is an antiepileptic/anticonvulsant drug used in adults and children. Gabapentin is marketed in capsules (100, 200 and 300 mg), tablets (600 and 800 mg) and an oral solution (250 mg/5 mL). The common daily oral dose range for adults is from 900 to 1800 mg per day in divided doses; pediatric doses (3 to 12 years of age) are dependent of the child's body weight and range from 10 to 15 mg/kg per day. Mean steady-state plasma levels (+/- SD) following daily regimens of: 900 mg/day = 1.88 (+/- 0.70) mcg/mL 1200 mg/day= 2.62 (+/- 0.86) mcg/mL Reported threshold for seizure control: Greater than 2 mcg/mL. The drug is also used to treat postherpetic neuralgia in adults. The common adult dosage for this indication is 1800 mg per day in divided doses following lower doses during initial treatment. The most common adverse effects of gabapentin are related to the central nervous system and include sedation, dizziness, nystagmus, ataxia and fatigue. All of these adverse effects are reversible and subside with reduction of dosage or discontinuation of therapy with the drug. 7. NMS v.18.0 CONFIDENTIAL Workorder Chain Patient ID 17337840 85116 2017-05939 Page 3 of 6 Reference Comments: Norfentanyl (Fentanyl Metabolite) - Femoral Blood: Norfentanyl is the primary inactive metabolite of the synthetic narcotic analgesic fentanyl. Substance(s) known to interfere with the identity and/or quantity of the reported result: Benzyl Fentanyl 8. Nortriptyline (Amitriptyline Metabolite; Aventyl®; Pamelor®) - Femoral Blood: Nortriptyline is a tricyclic antidepressant drug used in the treatment of affective (mood) disorders, principally major depression. It is also a metabolite of the antidepressant amitriptyline (Elavil®). Peak plasma levels are achieved at about 8 hr. Optimal therapeutic plasma levels for control of depression range from 50 - 150 ng/mL. Following chronic daily oral doses of 150 - 250 mg, reported steady-state plasma levels averaged 170 - 380 ng/mL, respectively. At plasma levels exceeding 200 ng/mL, toxic side effects such as hyper- or hypotension, tachycardia, cardiac arrhythmias, confusion and nausea may be present; severe overdose may result in convulsions, coma and cardiac irregularities. Following ingestion of 2000 mg of nortriptyline, a plasma concentration of 900 ng/mL was reported in a patient who later died after ventricular tachycardia, convulsions and then cardiovascular collapse. Postmortem blood concentrations of tricyclic antidepressants can depend on the anatomic source of the blood specimen. Concentrations may be higher in blood from visceral organs and the major vessels associated with them than actual antemortem circulating levels. 9. Sertraline (Zoloft®) - Femoral Blood: Sertraline is a selective serotonin reuptake inhibitor used in the treatment of depression. The initial adult dosage is 50 mg daily and can be increased to a maximum of 200 mg daily. Sertraline is subject to significant first pass metabolism with desmethylsertraline as the principal metabolite. Overdose with sertraline may cause sleepiness, nausea, tachycardia, and mydriasis. Fifteen adults taking 200 mg daily sertraline had mean trough serum concentrations of 29 ng/mL (range 9 - 82 ng/mL) sertraline. The blood to plasma ratio for sertraline is approximately 1.2. In a report of seven postmortem cases in which sertraline was not related to the cause of death, sertraline concentrations were 230 - 460 ng/mL in heart blood. Postmortem blood sertraline concentrations greater than 1,500 ng/mL were considered to be contributory to death in a review of 75 cases. A patient survived an acute overdose with a serum concentration of 2,900 ng/mL sertraline. Her symptoms included confusion, agitation, fever and seizures. 10. Sample Comments: 001 Physician/Pathologist Name: Dr. Matthew Cain/Dr.Mark Giffen Chain of custody documentation has been maintained for the analyses performed by NMS Labs. Unless alternate arrangements are made by you, the remainder of the submitted specimens will be discarded six (6) weeks from the date of this report; and generated data will be discarded five (5) years from the date the analyses were performed. William H. Anderson, Ph.D., F-ABFT Forensic Toxicologist Workorder 17337840 was electronically signed on 11/14/2017 20:39 by: NMS v.18.0 CONFIDENTIAL Workorder Chain Patient ID 17337840 85116 2017-05939 Page 4 of 6 Analysis Summary and Reporting Limits: All of the following tests were performed for this case. For each test, the compounds listed were included in the scope. The Reporting Limit listed for each compound represents the lowest concentration of the compound that will be reported as being positive. If the compound is listed as None Detected, it is not present above the Reporting Limit. Please refer to the Positive Findings section of the report for those compounds that were identified as being present. Acode 2143B - Gabapentin, Blood - Femoral Blood -Analysis by High Performance Liquid Chromatography/ TandemMass Spectrometry (LC-MS/MS) for: Compound Rpt. Limit Compound Rpt. Limit Gabapentin 1.0 mcg/mL Acode 52116B - Sertraline and Desmethylsertraline Confirmation, Blood (Forensic) - Femoral Blood -Analysis by High Performance Liquid Chromatography/ TandemMass Spectrometry (LC-MS/MS) for: Compound Rpt. Limit Compound Rpt. Limit Desmethylsertraline 20 ng/mL Sertraline 10 ng/mL Acode 52149B - Acetyl Fentanyl Confirmation, Blood (Forensic) - Femoral Blood -Analysis by High Performance Liquid Chromatography/ TandemMass Spectrometry (LC-MS/MS) for: Compound Rpt Limit Compound Rpt Limit Acetyl Fentanyl 0.10 ng/mL Acode 52168B - Amitriptyline and Metabolite Confirmation, Blood (Forensic) - Femoral Blood -Analysis by Gas Chromatography (GC) for: Compound Rpt. Limit Compound Rpt. Limit Amitriptyline 20 ng/mL Nortriptyline 20 ng/mL Acode 52484B - Fentanyl and Acetyl Fentanyl Confirmation, Blood (Forensic) - Femoral Blood -Analysis by High Performance Liquid Chromatography/ TandemMass Spectrometry (LC-MS/MS) for: Compound Rpt Limit Compound Rpt Limit Acetyl Fentanyl 0.10 ng/mL Fentanyl 0.10 ng/mL Norfentanyl 0.20 ng/mL Acode 8050U - Postmortem, Urine Screen Add-on (6-MAM Quantification only) - Postmortem Urine -Analysis by Enzyme Immunoassay (EIA) for: Compound Rpt. Limit Compound Rpt. Limit Amphetamines 500 ng/mL Barbiturates 0.30 mcg/mL Benzodiazepines 50 ng/mL Cannabinoids 20 ng/mL Cocaine / Metabolites 150 ng/mL Fentanyl / Metabolite 2.0 ng/mL Methadone / Metabolite 300 ng/mL Opiates 300 ng/mL Oxycodone / Oxymorphone 100 ng/mL Phencyclidine 25 ng/mL Acode 8051B - Postmortem, Basic, Blood (Forensic) - Femoral Blood -Analysis by Enzyme-Linked Immunosorbent Assay (ELISA) for: Compound Rpt. Limit Compound Rpt. Limit Amphetamines 20 ng/mL Barbiturates 0.040 mcg/mL NMS v.18.0 CONFIDENTIAL Workorder Chain Patient ID 17337840 85116 2017-05939 Page 5 of 6 Analysis Summary and Reporting Limits: Compound Rpt. Limit Compound Rpt. Limit Benzodiazepines 100 ng/mL Buprenorphine / Metabolite 0.50 ng/mL Cannabinoids 10 ng/mL Cocaine / Metabolites 20 ng/mL Fentanyl / Acetyl Fentanyl 0.50 ng/mL Methadone / Metabolite 25 ng/mL Methamphetamine / MDMA 20 ng/mL Opiates 20 ng/mL Oxycodone / Oxymorphone 10 ng/mL Phencyclidine 10 ng/mL -Analysis by Headspace Gas Chromatography (GC) for: Compound Rpt. Limit Compound Rpt. Limit Acetone 5.0 mg/dL Ethanol 10 mg/dL Isopropanol 5.0 mg/dL Methanol 5.0 mg/dL Acode 8063B - Postmortem, Basic to Expanded Upgrade, Blood (Forensic) - Femoral Blood -Analysis by High Performance Liquid Chromatography/Time of Flight-Mass Spectrometry (LC/TOF-MS) for: The following is a general list of compound classes included in this screen. The detection of any specific analyte is concentration-dependent. Note, not all known analytes in each specified compound class are included. Some specific analytes outside these classes are also included. For a detailed list of all analytes and reporting limits, please contact NMS Labs. Amphetamines, Anticonvulsants, Antidepressants, Antihistamines, Antipsychotic Agents, Benzodiazepines, CNS Stimulants, Cocaine and Metabolites, Hallucinogens, Hypnosedatives, Hypoglycemics, Muscle Relaxants, Non￾Steroidal Anti-Inflammatory Agents, Opiates and Opioids. NMS v.18.0 CONFIDENTIAL Workorder Chain Patient ID 17337840 85116 2017-05939 Page 6 of 6