It is only fitting and proper for the medical examiner’s office to express its thanks and

Joshua A. Perper, M.D., LL.B., M.Sc.
Chief Medical Examiner
March 26, 2007
It is only fitting and proper for the Medical Examiner’s Office to express its thanks and appreciation to Chief Charlie Tiger and the Seminole Police Department, including Detective Katheran Frank, for their valuable and continuous cooperation, professionalism and their thorough investigation into the death of Anna Nicole Smith and for sharing with us the results of I would also like to thank Sheriff Ken Jenne and the officers of the Broward County Sheriff’s Office for their prompt and outstanding help in providing additional needed security protection for our building. We realize that Sheriff Jenne’s workforce is limited but he nevertheless provided help 24 hours a day for more than 4 weeks while continuing to meet the needs of the citizens of Broward County. We are profoundly thankful to Sheriff Jenne and his officers for their willing and crucial assistance. Although Chief Medical Examiners become the focus of the public eye and are under the glare of TV cameras, they are not soloists. We work with a team of experts and technicians and any Chief Medical Examiner is only as good as his or her team. Broward County is fortunate to have an outstanding team of forensic pathologists and support staff. I would be greatly remiss if I did not acknowledge the essential contributions of our Medical Examiner team to the successful resolution of a rather complex case, all the while operating under intense public and media They are: Dr. Stephen Cina, Deputy Chief Medical Examiner; Dr. Gertrude Juste, Associate Medical Examiner with whom I performed the autopsy; Dr. Harold Schueler, Chief Toxicologist; Ms Edwina Johnson, Chief Medicolegal Investigator; Dr. Reinhard Motte, Associate Medical Examiner; Wendy Crane, Medicolegal Investigator; and our autopsy crew: Dean Reynolds, Chief autopsy technician; Irma Moten, autopsy technician; Joe Anderson and James Fleurimond, imaging technicians; and the invaluable assistance of Ms. Sherri Baker, my administrative assistant. I would also like to recognize the contribution of the rest of my staff who kept up with the regular day-to-day operations of this busy office despite significant We are also very thankful to Miami-Dade Police Department Forensic Computer Section for providing technical expertise that allowed us to search the two computers of Miss Smith for additional information possibly related I would also like to express our gratitude to six professional experts who volunteered their time, knowledge and expertise in assisting us in this investigation: Dr. Steven Nelson, forensic neuropathologist and Chief Medical Examiner of Polk County; Dr. Michael Bell, forensic cardiopathologist, and Chief Medical Examiner of Palm Beach County, Dr. Azorides Morales, cardiopathologist, and Professor and Chairman of Department of Pathology, University of Miami School of Medicine; Dr. Gordon Dickinson, Professor and Chief of the Division of Infectious Diseases, University of Miami School of Medicine; Dr. Margaret Gorensek Chair of the Department of Infectious Disease at the Florida branch of the Cleveland Clinic and Dr. Michael G. Bayerl, Assistant Professor of Anatomic Pathology at Milton S. Hershey Medical Center, College of Medicine. Their contributions were very important in our resolution of the Before disclosing our findings and conclusions as to Miss Smith’s cause, mechanism and manner of death, I have to address an important issue. Clearly, the people who unfortunately die and come under the jurisdiction of the Medical Examiner represent an irreparable loss to their loved ones. However, for us, they are first and foremost patients and we take great care to treat them with the utmost respect, as all patients fully deserve. All patients have a general right to privacy. This is obviously a very important shield because many of us may have had experiences or medical conditions which we would not like to have publicly exposed. The patients seen by the Medical Examiner, however, lose most of this right to privacy except for the confidentiality of medical records and photographs taken during autopsy. Much of the remainder of our findings is a matter of public record and they are open to review by anyone. We are careful not to disclose unnecessary public information or to sensationalize our findings; however, we also have a crystal clear and unreserved obligation under the law to fully and truthfully disclose our public records. We are acutely aware that such disclosure may disturb, embarrass or cause grief to relatives, friends or loved ones of the deceased. However, we do not Therefore, I would like to apologize in advance to Anna Nicole Smith’s family, friends who loved her, and her many fans for any disclosure of our public records which may be embarrassing or hurtful, but we must do what I am keenly aware that this tragic death has been under close scrutiny for a number of weeks. Rumors have abounded and speculations regarding our findings have flooded the airwaves. We acknowledge that this case has taken several weeks to thoroughly investigate and we deeply appreciate the patience of the media, the general public, and the loved ones of Miss Smith. We must keep in mind, however, that ultimately we are charged with the determination of the cause and manner of death. Sometimes, in cases like this, exhaustive testing is required to reach the correct conclusions, and we utilized all available means at our disposal to reach our conclusions. Forensic investigation of Anna Nicole Smith (Vickie Lynn Marshall) by the Broward County Medical Examiner’s Office In the afternoon of Thursday February 8, 2007, at 14:29 hours, the Broward County Medical Examiner Office was informed that Anna Nicole Smith, a 39 year-old woman, was found unresponsive in her suite at the Seminole Hard Rock Hotel and Casino. Resuscitation efforts failed and she was subsequently pronounced dead at Hollywood Memorial Regional Hospital. The preliminary information was rather sketchy, indicating that Miss Smith had arrived three days prior to her demise in Fort Lauderdale, and had The Medical Examiner assumed jurisdiction over the case, because the death was sudden, unexpected and unexplained. Dr. Gertrude Juste an Associate Medical Examiner examined Miss Smith at the Hospital and accompanied Dr. Juste also examined the scene of death and obtained multiple bottles of prescription medication. There was no evidence of “foul play” and no Immediately upon arrival of the deceased to the ME office, an external examination was conducted that revealed evidence of old plastic surgery but Samples of blood, body fluids and swabs of body orifices were taken for bacteriological, viral and serological studies and DNA profiling. An autopsy was performed the next day, February 9, 2007, at 10:36 hours by Dr. Joshua A. Perper and Dr. Gertrude Juste, and lasted about 6 hours. The gross examination disclosed only meager findings including: minor bruises of the back of the shoulders (related to a recent fall), scars of prior breast surgery but no evidence of recent plastic surgery, minor discoloration of heart muscle and the lining of the intestines, a congested enlarged liver, and a small amount of blood (less than an ounce) in the stomach consistent At the completion of the autopsy, it seemed that the cause of death may be a natural disease process, a drug overdose or toxicity or a combination of the Additional samples were taken at autopsy and a large number of tests were scheduled to be performed on blood and other biological samples, including microscopic examination, bacteriological cultures, viral cultures, serological studies, and a large array of toxicological tests for drugs, medications and toxic substances. The initial microscopic examination revealed no evidence It appeared at that time, that the death was most likely due to a chemical substance, drugs, medications or toxic substances. We subsequently reviewed various medical records, examined many bottles of prescribed medications and interviewed multiple individuals, including companions, treating physicians, and other witnesses. From the interviews of the witnesses, we obtained the following background information. Miss Smith suffered back and abdominal pain and was on a number of pain medications including Methadone. She was also taking “longevity” drugs, some alleged to be also weight reducing medications, including Human Growth hormone, Vitamin B12 and immunoglobulins, by injection into the After the death in 1996 of Howard Marshall, her husband, she experienced bouts of depression and had been admitted to Betty Ford Clinic. Three days after her son Daniel died in September 2006, Miss. Smith delivered a daughter by Cesarean section. Miss Smith developed a severe depression, which gradually decreased over time and was treated with anti-depressants and anti-anxiety drugs. Miss Smith was also under the stress of a number of Time table of events preceding the death of Miss Smith
During the three days preceding the flight to the United States, Miss Smith felt quite good and did not voice any complaints. Her appetite was very good. Medications included Methadone for pain and Growth hormone, an alleged “longevity”/weight reducing medication. She also had an injection into her left buttock of either Growth Hormone, Vitamin B12 or Monday February 5, 2007: The day of air flight to U.S.A. Miss Smith felt good. At 10:a.m. she had a dance lesson in preparation for an upcoming event for TrimSpa, and in anticipation of a music video that In the early afternoon, she flew to the United States in the company of Howard K. Stern, her partner and Dr. Kristine Eroshevich a psychiatrist/friend. During the flight she felt very well and was in good spirits, but complained of pain in the injected buttock when sitting. Due to a pilot error, the plane landed in Miami at about 4:30 p.m. and the group cleared customs and then flew to Fort Lauderdale. While riding in the limo to the hotel, Miss Smith complained of feeling very cold and had the chills. After the limo arrived at the hotel at about 7:30 p.m., Miss Smith went to bed. Her temperature was 105 degrees and friends wanted to call 911 for transportation to a hospital Emergency Room but she firmly refused. She was then prescribed and given Tamiflu, antibiotics, plenty of fluids and placed in an ice bath to lower her high temperature. Following the ice-bath, her temperature dropped to 97 degrees, and she felt a little better. In the evening she was given cough syrup but could not retain it and vomited. She then was given two table spoons of Chloral Hydrate (a sedative/sleeping medication) and went to sleep. Tuesday February 6, 2007- Second day in United States Miss Smith watched TV and did not complain except for tiredness. She was not depressed. She had no appetite but drank various fluids including Pedialyte, Chamomile tea and Figi water. In the afternoon she did not feel well, was sweating profusely and had a pungent odor but her temperature did not exceed 100 degrees. After a bath the odor faded and she felt a little better. She had no diarrhea, nausea or vomiting and was strong enough to That evening she wanted to sleep, asked for more Chloral Hydrate, and slept for 1-2 hours. After waking up she watched TV. In the evening she asked and was given Klonopin, Soma, Valium and Topomax. Before going to sleep she took another dose of Chloral Hydrate. Wednesday, February 7, 2007, third day in U.S.A. She felt better, no abdominal pain, no diarrhea, but felt very tired. She watched TV while reclining in bed. She was able to eat breakfast/lunch (an egg-white omelette with spinach), at around noon. In the afternoon she was found naked sitting in a dry bathtub. In the evening she ate two crab cakes and shrimp for dinner. Later Miss Smith was very upset after Dr. Eroshevich, her psychiatrist/friend left for California. In the evening she watched TV again until late in early morning and took another dose of Chloral Hydrate and went to sleep, but reportedly did not sleep well. Thursday, February 8, fourth day in USA and the day of death According to Mr. Howard K. Stern, he woke up around 10 am and found Miss Smith awake, with no complaints, except for excessive tiredness. Mr. Stern helped Miss Smith go to the bathroom and then put her back in bed. According to Mr. Howard Stern, he did not see Miss. Smith take or being given any medications that morning. Mr. Stern then left to arrange the Miss Smith was then watched by the wife of a bodyguard/firefighter friend, between 12-1:00 p.m. She was found in bed at 1:00 p.m. unresponsive. CPR was immediately performed upon her discovery by Tasma, Mo’s wife, a registered nurse and later resuscitation efforts by Big Mo and medics were also unsuccessful and Miss Smith was pronounced deceased at 2:49 p.m. at After the autopsy, we initiated a series of witness interviews. Several days after our initial examinations we were informed that during the air flight from the Bahamas to the United States and during the subsequent limousine ride to the hotel, Miss Smith complained of discomfort and pain in the left buttock, which she allegedly injected several days prior to departure. The body was than re-examined, and the buttocks appeared unremarkable, except for small non-descript scars and mild dimpling. However, dissection of the buttocks revealed extensive scarring with necrosis (destruction) of the fat tissue and formation of cysts. The left buttock contained several abscesses measuring up to one inch in diameter and multiple hemorrhagic needle tracks, one perforating an abscess. (Acetinobacter and Pseudomonas) were cultured from the pus. Cultures of the blood were negative, probably because Miss Smith had been on antibiotics. Tests showed markers of inflammation, but markers of sepsis (“blood poisoning”) were excluded. The infectious disease experts were in agreement with us that the very high fever of 105 degrees was related to release of bacteria into the blood from the abscesses of the buttock, which was partially treated by the antibiotics. An apparent viral infection of the intestines likely contributed to “stomach flu” symptoms. It is also possible that she had caught “the flu” from Mr. At this stage of the investigation the cause of death appeared to be a combination of natural death and possibly medications/drugs. As additional toxicological tests started to come in we found that the blood was free of common drugs of addiction such as opiates, cocaine, fentanyl etc. Methadone was negative in the blood but was positive in the bile indicating prior use, more than 3 days prior to death. It did not contribute to death. A large array of special studies excluded a variety of poisons from cyanide and phosphorus to heavy metals (such as mercury, lead) and more rare substances such as Thallium or abnormal concentrations of succinylcholine. Further toxicology revealed therapeutic concentrations of a number of anti-depressant/anti-anxiety and other medications including: Acetaminophen (Tylenol), Topomax, Diphenhydramine (Benadryl), Clonazepam (Clonopin), Diazepam (Valium), Lorazepam (Ativan), Meprobamate (from Soma) and Methocarbamol (Robaxin). The cause of death appeared at that time to be primarily a natural infectious However, on the third week after the autopsy, we received important toxicological result indicating the presence of high toxic/lethal blood levels of Chloral Hydrate, her sleeping medicine. Based on the totality of the results we finally concluded that the primary cause of death was: “Combined drug intoxication” with the primary drug being Chloral Hydrate in conjunction with multiple other drugs in therapeutic concentrations. When many drugs act together, they may often have unpredictable and dangerous effects. We further determined that abscesses of buttocks and viral enteritis (intestinal infection), and possibly the flu were contributory causes of death. Our next statutory obligation was to determine the manner of death. The manner of death is a determination of the circumstances in which death occurred. The options are natural, or not-natural i.e., accidental, suicidal, homicidal or undetermined. Forensic Pathologists are the only physicians who are trained to determine the manner of death. The determination of the manner of death is based on the integration of autopsy findings and tests (including toxicology), clinical information, and ME and police investigations. The selection of a particular manner of death (suicide, homicide, accident, or undetermined) should be balanced against the others, and should consider only facts and not speculations. In the case of Miss Smith the following facts support the determination of 1. The Chloral Hydrate level, though high would not be necessarily lethal in all cases and may not have killed her if other drug were not 2. In most cases of suicide, the victim ingests a large amount of a drug to insure death. In this case, there was a lot of Chloral Hydrate left in 3. In many cases of prescription drug overdoses, multiple drug levels are elevated since a person is likely to take many of the available pills. In this case, all drugs except Chloral Hydrate were at therapeutic 4. Statements of “wanting to die” after the death of her son Daniel in September 2006, were absent after mid October 2006. 5. A near drowning episode in a pool following Daniel’s death, appears to be a result of an accidental drug overdose rather than a suicidal act. Indeed, she thanked the individual who had resuscitated her rather 6. Miss Smith has a long history of prescription drug abuse, and self- 7. Miss Smith was likely not aware of the risks of using multiple drugs while in a physically vulnerable state consequent to her infections. She may have taken the dosages she was accustomed to but succumbed since she was already weakened. 8. Miss Smith had just had a baby and was generally in good spirits. 9. There was no suicide note, (though these are absent in many suicides). 10. Chloral Hydrate is rapidly broken down in the blood. In this case, only its active metabolites were detected. If a massive dose had been taken, death would have occurred so rapidly that Chloral Hydrate 11. Miss Smith had made definitive plans for the future including music videos, marriage, vacation and having another baby. There was no The following facts raised the possibility of suicide but were overshadowed 1. Miss Smith suffered severe, intermittent depression following the loss of her son Daniel, to whom she was extremely attached. 2. 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 postpartum 3. Though it is unclear, Miss Smith may have threatened to kill herself after Daniel’s death, and possibly even attempting to do so by 4. Miss Smith declared a long time ago that she wished to die in the same fashion as her idol, Marilyn Monroe, who died by suicide. Miss Monroe also employed Chloral Hydrate (in combination with a barbiturate) in her own highly publicized death. 5. While chronically depressed, Miss Smith experienced additional significant physical stressors: probable flu, the abscesses and probable viral enteritis. Severe illnesses may be associated with depression and constitute a recognized risk factor for suicide. 6. Several months prior to her death, Miss Smith bought several plots in a Bahamian cemetery and had possibly commissioned a dress for her The Exclusion of Homicide
- Given the level of the Chloral Hydrate in Miss Smith’s blood someone would have to either force-feed or have her voluntarily ingest a large amount - There was no oral trauma to suggest force-feeding; - Chloral Hydrate has a very pungent odor and a very unpleasant, harsh taste which would be easily detectable if it was “slipped: into a drink; - There were no other significant injuries. The cause of death is combined drug toxicity (Chloral Hydrate and therapeutic concentrations of other medications. A bacterial infection, viral enteritis and possibly flu were contributory causes of death. The manner of death is Accident.


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