Autopsy and Toxicology

Morgan’s Autopsy:

The Pathology Group, P.C.

Dean M. Havlik, M.D. Robert A. Kurtzman, D.O. Tara L. Marshall, M.D.
2021 N. 12th Street ● Grand Junction, Colorado 81501 ● (970) 256-6462

REVISED POSTMORTEM EXAMINATION REPORT

NAME:

Morgan Ingram CASE #: 11-289 Complete Autopsy

IMMEDIATE CAUSE OF DEATH INTERVAL

A. Amitriptyline intoxication Minutes to hours

OTHER SIGNIFICANT CONDITIONS: None

ADDENDUM INFORMATION AND OPINION RECLASSIFICATION

Contrary to the initial representation and documentation of porphyria as a presumptive diagnosis for the decedent, the certainty of the diagnosis of porphyria as the underlying cause of death, and manner of death classification as natural, has been questioned; therefore, additional investigation and medical information from various sources and facilities has been collected and reviewed. A portion of the information sought has included medical records that might assist in including or excluding inherited heart rhythm syndromes or other potential causes of sudden death. Based upon the acquisition of the additional information, additional testing was performed and updated status of the stalking investigation was sought.

Analysis of the decedent’s postmortem toxicology report, specifically the Amitriptyline level, was reconsidered. As noted in the report issued on December 19, 2011, Amitriptyline is subject to postmortem redistribution. The postmortem blood level of Amitriptyline may increase by an average of 3.1 times (range 0.6 to up to 15 times) when compared to antemortem samples. Individuals taking Amitriptyline over long periods of time may experience higher levels than Amitriptyline-naïve patients. The decedent in this case appears to have been first prescribed Amitriptyline in 2003, a time period of 8-9 years of use. The decedent’s postmortem blood concentration of 7909 ng/mL of Amitriptyline and 2833 ng/mL of Nortriptyline is 2.1 times higher than the average fatal Amitriptyline blood concentration of 3.7mg/L (range 2.7 – 4.7) and therefore potentially within the range of the effects of postmortem redistribution. No intact or partially intact pill fragments were identified in the gastric contents during the postmortem examination and gastric contents were not initially submitted for evaluation. The results of the toxicology analysis were reviewed with a toxicologist from AIT Laboratories prior to issuing the report dated December 19, 2011. In consideration of the case review, the gastric contents were sent for analysis on June 6, 2012. The results of the analysis of the gastric contents revealed a 2287440 ng/mL concentration of Amitriptyline. Although the exact number of pills ingested cannot be determined, based upon the stomach content volume and Amitriptyline concentration, approximately 18 tablets of 25 mg Amitriptyline tablets would be necessary to reach such a concentration. The amount of ingested drug is far in excess of the prescribed dosage and far in excess of a typical inadvertent over dosage. A 175 ng/mL concentration Cyclobenzaprine was also found in the stomach contents. The amount consumed is consistent with a deliberate intoxication. The results were reviewed again with a toxicologist

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from AIT Laboratories. In consideration of the findings, the postmortem blood Amitriptyline level is considered to be a lethal level rather that an artifact of postmortem redistribution. No information gathered thus far provides objective support for an inherited heart rhythm syndrome including an EKG reported on October 8, 2009. No reviewed information unequivocally excludes the diagnosis of porphyria and in fact, according to the medical record, porphyria was considered the tentative working diagnosis for the decedent’s chronic recurrent abdominal pain. Genetic testing was contemplated but was not completed. In consideration of the above findings the cause of death is reclassified as Amitriptyline intoxication due to an ingested Amitriptyline overdose.

With regard to the stalking investigation, there are no objective conclusive findings or reports made available to me by law enforcement or any other source to support an opinion that the death is directly attributable to another person or persons. There was indication that the decedent was concerned and stressed regarding a stalker. There was no indication of any trauma. There has been no objective evidence produced to indicate that another individual was physically present at the time of intoxication. There is no evidence of a struggle or evidence to indicate that the decedent was physically forced to ingest Amitriptyline. Therefore the manner of death is reclassified as suicide. If objective information is produced indicating that the decedent was somehow forced against her will to consume an Amitriptyline overdose and observed until incapacitated the manner of death may be reclassified as homicide.

MANNER OF DEATH:

Suicide

___________________________________________ Date: July 28, 2012

Robert A Kurtzman, DO

Forensic Pathologist

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AGE: 20

RACE: Caucasian

GENDER: Female

DATE OF BIRTH: August 16, 1991

DATE & TIME OF DEATH: Found Friday, December 2, 2011 time of death unknown

PRONOUNCED DEAD BY:

Thomas Walton, Garfield County Deputy Coroner

DATE & TIME PRONOUNCED DEAD:

Friday, December 2, 2011 at 815

LOCATION OF DECEDENT:

062 Corral Dr. Carbondale, Garfield County, CO

LAW ENFORCEMENT AGENCY INVESTIGATING DEATH:

Garfield County Sheriff’s

Office Eric Ashworth

EXAMINATION AUTHORIZED BY:

Garfield County Coroner’s Office

BODY TRANSPORTED TO MORGUE BY:

Farnum Holt Funeral Home (Frank Breece)

ACCESS TO MORGUE BY:

Kim Hollingshead on Friday, December 2, 2011 at 1334

TIME OF REFRIGERATION:

Not applicable

BODY WRAP:

Body bag

BODY IDENTIFICATION:

Garfield County Coroner’s Office

LOCATION OF POSTMORTEM EXAMINATION:

Community Hospital, Grand Junction, CO

DATE & TIME OF POSTMORTEM EXAMINATION:

Friday, December 2, 2011 at 1334

AUTOPSY ASSISTANT:

Kim Hollingshead

EXTERNAL EXAMINATION

(not including injury): The body is that of a normally developed, well nourished female who appears appropriate for the reported age. The body length is 63 inches and the weight is 115 pounds (BMI 20.4). The decedent is clad in green jeans, a white T-shirt, a tan bra, pink underwear and blue prints socks. The T-shirt and bra have been cut away by emergency medical responders. The eye and body is preserved well in the absence of embalming, lividity is anterior shifting posterior, not fixed and rigidity is incomplete. The head is normocephalic and the scalp is covered by straight brown hair up to 14 inches in length. The ears are normally formed. The right earlobe pierced once and the left earlobe pierced twice. The eyes are gray green and the corneae are clear.

There are no petechiae on the conjunctivae or sclerae. The periorbital regions are unremarkable. The nose is intact to palpation. The teeth are natural. There are no focal lesions on the oral or buccal mucosae. The neck, chest and abdomen have normal contour without deformity. All four extremities are present and are normally developed. The decedent’s toenails are painted purple. The decedent’s fingernails are painted with clear gloss and the tips are painted white. The genitalia appear normal and there is no trauma. The pubic hair is shaved.

4

SCAR(S):

The decedent does not have any distinguishing scars.

TATTOO(S):

The decedent does not have any tattoos

EVIDENCE OF MEDICAL TREATMENT:

The decedent has two defibrillation pads and four EKG pads.

EVIDENCE OF INJURY:

The decedent does not have any significant injury.

INTERNAL EXAMINATION:

The body is opened utilizing a Y-incision. The adipose tissue is bright yellow and the cut surface is unremarkable. The underlying skeletal muscle is unremarkable.

THORACOABDOMINAL CAVITY:

The contents of the thorax and abdomen are present in their usual location and have normal anatomic relationship. The pleura and peritoneum are smooth and there is no excess free fluid or free air.

CARDIOVASCULAR SYSTEM:

The aorta is normally developed and has normal distribution. There is no significant atherosclerosis. The venae cavae are unremarkable. The pericardial sac lining is smooth and the pericardial fluid is not increased. The epicardium of the heart is smooth and unremarkable and the heart is 190 grams. The great vessels arise in the usual manner and the right and left atria are normally formed. The right and left ventricles are normally formed. There are no focal lesions on the endocardium or cut surface of the myocardium. The cardiac valves are normally formed, soft and pliable without calcifications, vegetations or fibrosis. The coronary arteries are normally formed and have normal distribution. There is no significant coronary artery atherosclerosis.

RESPIRATORY SYSTEM:

The right and left lungs are 470 and 380 grams, respectively. Both lungs have normal lobulation and the pleura is smooth and pink-red. There are no focal lesions. The cut surface of the pulmonary parenchyma is edematous and slightly congested. The bronchi and pulmonary vasculature are normally formed. There are no foreign objects in the airways.

NECK ORGANS:

The tongue is normally formed and there are no bite marks on the surface. The epiglottis is not enlarged and the laryngeal mucosa is smooth. There is no hemorrhage on the cut surface of the laryngeal mucosa and there are no foreign objects in the upper airway. The thyroid cartilage, thyroid cornu and hyoid bone are intact. The strap muscles of the neck are unremarkable.

GASTROINTESTINAL SYSTEM:

The esophagus traverses the posterior mediastinum in the usual manner before passing through the intact diaphragm and connecting with the stomach. The stomach contains approximately 200 milliliters of variegated yellow/orange fluid. The mucosa is smooth and there is no ulceration. The small intestine, large intestine, mesentery and omentum are unremarkable. The appendix is unremarkable.

HEPATOBILIARY SYSTEM:

The liver is 1410 grams and has normal lobulation. The brown, smooth surface is intact. There are no focal lesions on the normal appearing cut surface. The bile ducts are normally formed. The gallbladder is normally formed and filled

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with yellow-green bile. The mucosa is smooth and there are no calculi. The pancreas is firm, tan and lobular, and there are no focal lesions on the normal appearing cut surface.

LYMPHORETICULAR SYSTEM:

The spleen is 140 grams. The smooth, red-blue surface is intact, and there are no focal lesions on the normal appearing cut surface. There is no cervical, thoracic or abdominal lymphadenopathy, and the thymus is unremarkable.

GENITOURINARY SYSTEM:

The right and left kidneys are 140 and 150 grams, respectively. The capsules strip easily and the cortex is red and smooth. The cut surface of the cortex and medulla is distinct and there is no blunting of the calyces or papillae. The ureters traverse the retroperitoneum in the usual manner before passing through the wall of the normally formed bladder. The bladder mucosa is smooth and tan. The vagina, cervix, uterus, ovaries and fallopian tubes are unremarkable and appropriate for the age of the decedent. The decedent has a hemorrhagic corpus luteum in the right ovary. The endometrium is thick tan red and soft. There is no intrauterine pregnancy grossly apparent.

ENDOCRINE:

The right and left adrenal glands are normally formed. The golden brown cut surface is unremarkable and there are no focal lesions. The thyroid has normal lobulation and there are no focal lesions on the normal appearing cut surface. The parathyroid glands are not enlarged and the pituitary is unremarkable.

CENTRAL NERVOUS SYSTEM:

The scalp is reflected in the usual manner and there are no contusions. The calvarium is intact without fracture. The dura is soft and pliable and there are no focal lesions. The leptomeninges are clear and the brain is 1450 grams.

There is no swelling, midline shift or herniation. The gyri and sulci are normally formed.

The vessels at the base of the brain and cranial nerves are normally formed. The cut surface of the cortex, white matter, central gray matter, brain stem and cerebellum are unremarkable. The ventricular system is normally formed and is not enlarged.

MICROSCOPIC EXAMINATION

CARDIOVASCULAR:

The myocardium has orderly architecture. There is no acute or chronic inflammation. There is no fibrosis or ischemic change. There is slight myocyte hypertrophy in a sub endocardial distribution.

RESPIRATORY:

The pulmonary parenchyma has orderly architecture and is congested and

edematous. There is no acute inflammation.

HEPATOBILIARY: The liver has orderly lobular architecture and has centrilobular congestion. There is no acute or chronic inflammation. There is no fibrosis or necrosis.

LYMPHORETICULAR: The spleen has orderly architecture and is congested.

GENITOURINARY: The kidney has orderly architecture and is congested. The uterus is lined by endometrium with elongate coiled secretory glands. There is no histologic abnormality. A section of the right ovary incorporates a recent hemorrhagic corpus luteum.

ENDOCRINE:

The thyroid has orderly architecture without histologic abnormality. A section of adrenal gland has orderly architecture without histologic abnormality and is congested.

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SUMMARY OF AUTOPSY

CARDIOVASCULAR: Unremarkable

RESPIRATORY: Pulmonary edema

NECK ORGANS: Unremarkable

GASTROINTESTINAL: Unremarkable

HEPATOBILIARY: Congestion

LYMPHORETICULAR: Congestion

GENITOURINARY: Congestion

Corpus luteum right ovary

ENDOCRINE: Unremarkable

CENTRAL NERVOUS SYSTEM: Unremarkable

MUSCULOSKELETAL/CUTANEOUS: Unremarkable

GENETIC/METABOLIC: History of presumptive acute intermittent porphyria

—————–

Morgan’s tox screen:

Morgan Ingram’s Autopsy and Tox Report
2265 Executive Drive, Indianapolis, IN 46241
Telephone: (800)875-3894 / Fax: (317)243-2789
Laboratory Case Number: 1822211 Subject’s Name: INGRAM, MORGAN
Client Account:
Physician:
Report To:
10126 / MECC02
Mesa County Coroner
ATTN: Dean Havlik
2021 N. 12th Street
PO Box 4235
Grand Junction, CO 81502
Agency Case #:
Date of Death:
Test Reason:
Investigator:
Date Received:
Date Reported:
NOT INDICATED
12/02/2011
Other
THOMAS WALTON
06/08/2012
07/10/2012
Laboratory Specimen No: 40258356 Date Collected:
Container(s): Test(s):
12/02/2011
01:GRT Blood,SUBCLAVICAL 70510 Comprehensive Drug Panel
Analyte Name Result Concentration Units Therapeutic Range Loc
AMPHETAMINES Negative
BARBITURATES Negative
BENZODIAZEPINES Negative
CANNABINOIDS Negative
COCAINE/METABOLITES Negative
FENTANYL Negative
METHADONE/METABOLITE Negative
OPIATES Negative
OXYCODONE/METABOLITE Negative
PHENCYCLIDINE Negative
PROPOXYPHENE/METABOLITE Negative
ALCOHOL Negative
Methanol Negative
Ethanol Negative
Acetone Negative
Isopropanol Negative
ANALGESICS Negative
ANESTHETICS Negative
ANTIBIOTICS Negative
ANTICONVULSANTS Negative

ANTIDEPRESSANTS
POSITIVE
Amitriptyline

POSITIVE
Amitriptyline, Quant 7909 ng/mL 10 – 250
INGRAM, MORGAN
Laboratory Case #: 1822211
Printed Date/Time: 07/10/2012, 16:03 Page: 1 of 7
2265 Executive Drive, Indianapolis, IN 46241
Telephone: (800)875-3894 / Fax: (317)243-2789
Laboratory Specimen No: 40258356 Continued..
Analyte Name Result Concentration Units Therapeutic Range Loc
Nortriptyline

POSITIVE
Nortriptyline, Quant 2833 ng/mL 5 – 150
ANTIHISTAMINES Negative
ANTIPSYCHOTICS Negative
CARDIOVASCULAR AGENTS Negative
ENDOCRINE AGENTS Negative
GASTROENTEROLOGY AGENTS Negative
NARCOTICS Negative
NEUROLOGY AGENTS Negative
SEDATIVES/HYPNOTICS Negative
STIMULANTS

POSITIVE
Cotinine POSITIVE
UROLOGY AGENTS Negative
Specimens will be kept for one year from the date received.
Please note: This is a revised report…Previous report issued
12/19/2011 did not include specimen 40288976. Additional sample has
been submitted for testing.
INGRAM, MORGAN
Laboratory Case #: 1822211
Printed Date/Time: 07/10/2012, 16:03 Page: 2 of 7
2265 Executive Drive, Indianapolis, IN 46241
Telephone: (800)875-3894 / Fax: (317)243-2789
Laboratory Specimen No: 40258357 Date Collected:
Container(s): Test(s):
12/02/2011
01:RTT Urine, Random 70080 Drugs of Abuse Panel
Analyte Name Result Concentration Units Therapeutic Range Loc
AMPHETAMINES Negative
BARBITURATES Negative
BENZODIAZEPINES Negative
BUPRENORPHINE/METABOLITE Negative
CANNABINOIDS Negative
CARISOPRODOL/METABOLITE Negative
COCAINE/METABOLITES Negative
FENTANYL Negative
METHADONE/METABOLITE Negative
OPIATES Negative
PHENCYCLIDINE Negative
PROPOXYPHENE/METABOLITE Negative
TRAMADOL/METABOLITE Negative
ALCOHOLS Negative
INGRAM, MORGAN
Laboratory Case #: 1822211
Printed Date/Time: 07/10/2012, 16:03 Page: 3 of 7
2265 Executive Drive, Indianapolis, IN 46241
Telephone: (800)875-3894 / Fax: (317)243-2789
Laboratory Specimen No: 40258358 Date Collected:
Container(s): Test(s):
12/02/2011
01:RTT Vitreous,EYE 70570 Autopsy Panel, Volatiles
Analyte Name Result Concentration Units Therapeutic Range Loc
ALCOHOL Negative
Methanol Negative
Ethanol Negative
Acetone Negative
Isopropanol Negative
INGRAM, MORGAN
Laboratory Case #: 1822211
Printed Date/Time: 07/10/2012, 16:03 Page: 4 of 7
2265 Executive Drive, Indianapolis, IN 46241
Telephone: (800)875-3894 / Fax: (317)243-2789
Laboratory Specimen No: 40258360 Date Collected:
Container(s): Test(s):
12/02/2011
01:RTT Blood,SUBCLAVICAL 49900 Not Tested
Analyte Name Result Concentration Units Therapeutic Range Loc
< No Testing Performed >
INGRAM, MORGAN
Laboratory Case #: 1822211
Printed Date/Time: 07/10/2012, 16:03 Page: 5 of 7
2265 Executive Drive, Indianapolis, IN 46241
Telephone: (800)875-3894 / Fax: (317)243-2789
Laboratory Specimen No: 40288976 Date Collected:
Container(s): Test(s):
12/02/2011
01:T Fluid,GASTRIC 70510 Comprehensive Drug Panel
Analyte Name Result Concentration Units Therapeutic Range Loc
AMPHETAMINES Negative
BARBITURATES Negative
BENZODIAZEPINES Unsuitable
Flurazepam Unsuitable (1)
Insufficient specimen volume remains to complete testing
Desalkylflurazepam Unsuitable (1)
Insufficient specimen volume remains to complete testing
CANNABINOIDS Negative
COCAINE/METABOLITES Negative
FENTANYL Negative
METHADONE/METABOLITE Negative
OPIATES Negative
PHENCYCLIDINE Negative
PROPOXYPHENE/METABOLITE Negative
ALCOHOL Negative
Methanol Negative
Ethanol Negative
Acetone Negative
Isopropanol Negative
ANALGESICS

POSITIVE
Cyclobenzaprine

POSITIVE
Cyclobenzaprine, Quant 175 ng/mL
ANESTHETICS Negative
ANTIBIOTICS Negative
ANTICONVULSANTS Negative
ANTIDEPRESSANTS

POSITIVE
Amitriptyline

POSITIVE
Amitriptyline, Quant 2287440 ng/mL
Nortriptyline

POSITIVE
Nortriptyline, Quant 9431 ng/mL
ANTIHISTAMINES Unsuitable
Guaifenesin Unsuitable (2)
Insufficient specimen volume remains to complete testing
INGRAM, MORGAN
Laboratory Case #: 1822211
Printed Date/Time: 07/10/2012, 16:03 Page: 6 of 7
2265 Executive Drive, Indianapolis, IN 46241
Telephone: (800)875-3894 / Fax: (317)243-2789
Laboratory Specimen No: 40288976 Continued..
Analyte Name Result Concentration Units Therapeutic Range Loc
ANTIPSYCHOTICS Negative
CARDIOVASCULAR AGENTS Negative
ENDOCRINE AGENTS Negative
GASTROENTEROLOGY AGENTS Negative
NARCOTICS Negative
NEUROLOGY AGENTS Negative
SEDATIVES/HYPNOTICS Unsuitable
Promethazine Unsuitable
Testing cancelled due to interference
STIMULANTS Negative
UROLOGY AGENTS Negative
Performing Location(s):
(1) MEDTOX Laboratories
402 W County Rd D, Saint Paul, MN 55112
Medical Director: Jennifer Collins, PhD, License #:
(2) National Medical Services
3701 Welsh Road, Willow Grove, PA 19090
Medical Director: G. John DiGregorio, MD, PhD, License #: 39DO197898
The Specimen identified by the Laboratory Specimen Number has been handled and analyzed in accordance with all applicable requirements.
INGRAM, MORGAN
Laboratory Case #: 1822211

Printed Date/Time: 07/10/2012, 16:03 Page: 7 of 7

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Autopsy Request Form

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Body Diagram from Autopsy

 

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