EL PASO COUNTY CORONER 2741 EAST LAS VEGAS STREET COLORADO SPRINGS, COLORADO 80906 NAME: WALTER, John COUNTY: FREMONT Date of Birth: 03/17/1961 Age: 53 AUTOPSY NO: 14-0319 AUTOPSY DATE: 04/25/2014 Sex: M He 71" We: 168 Ibs. BEGAN: 8:30 AM MD: Emily Berry, M.D. DATE OF DEATH: — 04/2022014 ‘TIME OF PRONOUNCEMENT: 5:57 PM Identified by: Visual FINAL DIAGNOSIS: 1. Acute benzodiazepine withdrawal: A. Decedent withdrawn from clonazepam without taper. B. Extensive contusions, abrasions, rib fractures, and right hemothorax (50 mL) in the setting of reported history of multiple incidents of self-injurious and combative behaviors and multiple incidents of “Use by Force” by jail staff. IL. Hypertensive cardiovascular disease: ‘A. Marked perivascular interstitial fibrosis. B. Clinical history of hypertension Il, Other findings: A. Steatosis. B. Moderately thickened anterior mitral valve leaflet. C. Benign gastric nodule. D. Guitar pick in stomach. OPINION: It is my opinion that the cause of death of John Walter, a 53-year-old adult White male, is acute benzodiazepine withdrawal. This autopsy report was amended on April 12, 2017 to reflect new information provided to me in this case to include pharmacy records, medical records, and deposition. transcriptions including one stating benzodiazepines were not administered despite written orders to taper the medication. The manner of death remains undetermined as any intent behind not providing the medication taper is not clear. MANNER OF DEATH: Undetermined Uc P bers, AD. EMILY R. BERRY, M.D. Lala tC Bug, oy ROBERT C. BUX, ON KELLY, M.D. ERB/gds April 25, 201714-0319, WALTER, John, PERSONS PRESENT AT AUTOPSY Detective Mike Miller of the Fremont County Sheriff's Office is present for the postmortem examination, GENERAL EXAMINATION The body is that of a normally-developed, well-nourished, adult White male, 71 inches tall, weighing 168 Ibs, and appearing compatible with the stated age of 53 years. The deceased is nude. A white sheet is with the decedent, The white sheet is discarded. No jewelry is present. Full body radiographs are performed, A.EL Paso County Coroner tag is on the decedent’ right wrist. EXTERNAL EXAMINATIO? ‘There is good preservation in the absence of embalming. Rigor mortis is dissipated in the extremities, jaw, and neck. Posterior lividity is fixed. The deceased has gray scalp hair averaging 6 inches in length. ‘The irides appear brown; the corneae are clear; and there are no petechiae of the bulbar or palpebral surfaces of the conjunctivae. ‘The ears, nose, lips, and external auditory canals are unremarkable. The mouth is edentulous. There is gray facial stubble. The external genitalia and perineum are unremarkable. A Yaiinch scar is near the midline of the forehead. A3 “4 inch linear vertical sear is on the extensor surface of the right foot. Except for the evidence of medical therapy and the injuries to be described, the remainder of the external examination of the body is unremarkable. EVIDENCE OF MEDICAL THERAPY ‘An endotracheal tube is secured to the head with a collar and has an attached Ambu bag. Defibrillator pads are on the chest. EKG stickers are on the body. An intraosseous access with attached intravenous fluid bag is in the right distal leg. A hot pink band is on the body labeled “4/20/2014 1740." On further examination of the body, left ribs 2-5 are disarticulated from the sternum which is fractured, all with minimal associated soft tissue hemorrhage. This findings is consistent with an artifact of attempted resuscitation, EVIDENCE OF INJURY On the right side of the forehead there are seven red abrasions, punctate to 3/8 x % x 1/8 with the largest in an angled U-shaped orientation. A 1 inch green contusion is anterior to the right ear. A 1 Ys anda 1% inch contusions are on the right side of the jaw. Three 1/16 inch red abrasions are on the posterior parietal scalp, A3 inch blue-brown contusion with 1 inch brown crusted linear abrasion is on the anterior right shoulder. A 2 inch blue contusion with 3/8 inch brown abrasion is on the anterior left shoulder. A S inch14-0319 WALTER, John. brown-purple contusion and a | '% inch brown contusion are on the right side of the chest. A 2% inch blue-purple contusion and a 7/8 inch blue contusion are on the left side of the anterior chest. AI ¥ inch red contusion is near the right groin. A.1 x % inch area of irregular punctate crusting is on the posterior medial shoulder and upper back. Three punctate red abrasions and aI % inch blue contusion are on the right side of the upper back. A 1 ‘inch, % inch, and ¥ inch blue contusion, 2 x 1 inch area of six linear red abrasions, 1/8 to 1 % inch in greatest dimension, and a 4 and % inch red abrasion are on the left side of the upper to mid back. A 4% x3 inch red to purple contusion with interrupted linear components | inch, 7/8 inch, and 7/8 inch apart and 1 % to 3 % inches in length is on the right side of the posterior waist. A % inch L-shaped faint red- brown crusted abrasion and a I % inch obtusely angled red abrasion are on the upper right buttock. Five red abrasions, punctate to 1/8 inch in greatest dimension, are on the right buttock. Eight red abrasions, 1/8 to 3/8 inch in greatest dimension, and a 3 % inch red contusion are on the left buttock. ‘A % inch blue contusion is on the anterior aspect of the right upper arm. A 4 inch superficial avulsion is. on the volar right wrist. A 5/8 and a % inch healing red-purple crusted linear abrasion are on the posterior aspect of the mid right upper arm. A ¥% inch red contusion, ¥ inch purple contusion, and 11 red to brown crusted abrasions, punctate to 3/8 inch in greatest dimension with associated | Ys inch brown contusion are in the area of the right elbow. Five brown crusted abrasions, punctate to 1/16 inch in greatest dimension, and a linear vertical 3 5/8 inch red healing abrasion are on the dorsal right forearm. A.7/8 inch red contusion is on the dorsal right hand. Two punctate red abrasions are on the dorsal right 4 finger. Nine red to red-brown abrasions, punctate to % inch in greatest dimension, a 1 % inch interrupted red- brown-golden abrasion, a 5/8 inch blue contusion, and a 5/8 inch red contusion are in the area of the left elbow. A % inch brown crusted abrasion and a punctate brown crusted abrasion are on the dorsal left wrist. A 3/8 inch red-brown crusted abrasion and a 1/8 inch superficial healing incised wound are on the dorsal left 3" finger. Three purple contusions, % to 3/8 inch in greatest dimension are on the anterior aspect of the right upper thigh. A punctate red abrasion, a 1 inch red contusion, and three I Ys to 2 % inch red to green to purple contusions are in the area of the right knee. Four light brown crusted abrasions, a ¥4 inch red subcutaneous hemorrhage, 3/8 inch superficial red abrasion, and three red-brown punctate to 1/8 inch abrasions are on the right shin. A 2% inch purple contusion is on the anterior aspect of the right ankle, ‘A% inch brown contusion is on the posterior right upper thigh. A % inch purple contusion is superomedial to the posterior aspect of the right knee. Six brown contusions, 3/8 to | 7/8 inch in greatest dimension, are posterior to the right knee. Four purple contusions, % to | % inches in greatest dimension, are on the posterior aspect of the right distal leg. A % inch blue contusion is above the posterior aspect of the right ankle. A 1 % inch and 2 inch blue-brown contusion and a 5/8 inch red- brown contusion are on the lateral aspect of the right thigh. A 3/8 inch brown crusted abrasion is on the lateral aspect of the right distal leg below the knee. A 5 inch purple contusion and a punctate red- brown crusted abrasion are on the lateral aspect of the right distal leg. Five punctate to 3/16 inch light brown crusted abrasions are on the posterior aspect of the right heel. A % inch superficial avulsion is on the right 5" toe. A 4 inch purple contusion is on the extensor surface of the right foot and great toe. The jereat toe has three red to brown abrasions, 1/16 to 1/8 inch in greatest dimension. The second toe has two red abrasions, 1/16 and 1/8 inch in greatest dimension, with a ¥ inch red-brown avulsion at the tip of the nail bed. The right fourth toe has a % inch blue nearly all-encompassing contusion which also involves the medial aspect of the fifth toe. A % inch superficial disruption is on the plantar surface of the14-0319 WALTER, John right foot near the heel and has the appearance of dry cracked skin. A 4 inch purple to brown contusion is on the lateral aspect of the right foot Red to purple contusions, % to 2 % inches in greatest dimension, and six red to red-brown crusted abrasions, punctate to 3/8 inch in greatest dimension, are on the left knee. Four punctate to % inch red to red-brown abrasions are on the lateral aspect of the left knee. Three red-brown erusted abrasions, punctate to % inch in greatest dimension and a 7/8 inch brown contusion are on the anterior aspect of the left distal leg above the ankle. A 1% inch purple-brown contusion is superolateral to the posterior aspect. of the left knee. A 1 inch purple contusion is on the extensor surface of the left foot. A 1/8 inch red- brown crusted abrasion is on the extensor surface of the left foot near the fourth and fifth toes. A 2.3/8 inch purple contusion is on the medial aspect of the left foot at the base of the great toe. A 5/8 inch brown abrasion is on the plantar surface of the left great toe. A ¥% inch avulsion is on the tip of the third toe. A | 1/8 inch brown crusted linear abrasion is on the left heel. 3/8 inch red-brown abrasion is on the tip of the third toe with three red-brown abrasions, % to 5/8 inch in greatest dimension, On reflection of the skin of the posterior body surfaces, a3 % inch area of subcutaneous hemorrhage is in the midline of the upper thoracie spine. A 7 inch area of subcutaneous hemorrhage is on the posterior aspect of the left upper hip. A 1% inch area of subcutaneous hemorrhage is on the posterior aspect of the right shoulder. (On examination of the ribs, there are fractures of the anterior aspect ofthe right 3" rib, left anterior ribs 2-5, and left anterolateral ribs $ and 6, posterolateral fractures of right ribs 2-8 and 10, and paravertebral fractures of right ribs 4-6. These fractures have significant surrounding hemorthage. ‘The right pleural cavity contains 50 mL of blood. INTERNAL EXAMINATIO! HEAD: The scalp is incised and retracted. The scalp, subscalpular area, and skull are unremarkable. The cranial vault is opened revealing thin, tough, pliable dura and no hemorrhage in the epidural ot subarachnoid spaces. ‘There is very thin non-space occupying slightly left greater than right subdural hemorrhage, The brain weighs 1330 gm and the cerebral hemispheres, midbrain, and pons are symmetrical and grossly unremarkable, On cross-section of the brain parenchyma, there is no evidence of infection, tumor, or trauma, The dura is stripped from the basilar skull and no fractures are found. BODY: The body is opened with a Y-shaped incision. The organs occupy their usual positions and relationships. The body cavities are free of adhesions. The right pleural cavity contains 50 mL of blood. The remaining body cavities are free of adhesions or abnormal collections of fluid. NECK: The hyoid bone and larynx are intact. The airway is patent and there is no evidence of infection or tumor. The thyroid gland and tongue are unremarkable. CARDIOVASCULAR SYSTEM: The intimal surface of the abdominal aorta is free of significant atherosclerosis. The heart weighs 320 gm. The epicardial and endocardial surfaces are smooth and glistening. Within the posterior aspect of the interventricular septum, there is focal apparent perivascular fibrosis. The remaining myocardium is uniformly firm and has a homogeneous, beefy-red appearance. ‘The left ventricular free wall is 1.5 cm thick. ‘The anterior leaflet of the mitral valve appears moderately thickened, The right-dominant coronary arteries are free of significant atherosclerosis.14-0319 WALTER, John LUNGS: The right lung weighs 550 gm and the left lung weighs 625 gm. The right lung has two lobes. The major bronchi are unremarkable. ‘The pleural surfaces are smooth and glistening and have a moderate anthracotie appearance. On cross-section, the parenchyma appears congested and edematous. ‘There are no pulmonary emboli GASTROINTESTINAL SYSTEM: The esophagus, stomach, small and large bowel, and appendix are unremarkable. A 1.8 x 1.3 x 0.5 em subserosal firm, tan nodule is on the anterior aspect of the gastric wall. The stomach contains approximately 75 mL of brown fluid and a tortoise shell pattern plastic guitar pick with grungy black appearance prior to cleaning, LIVER: The liver weighs 1450 gm. The capsule is smooth and glistening. The parenchyma is dark red- brown, moderately congested, and firm. The gallbladder contains 50 mL of dark green bile with no calculi PANCREAS: Unremarkable. ADRENAL GLANDS: Unremarkable. SPLEEN: The spleen weighs 175 gm and the capsule is smooth and blue-gray. On cross-section, the parenchyma is unremarkable. KIDNEYS: The right kidney weighs 175 em and the left kidney weighs 200 gm. The capsules strip with ease revealing smooth cortical surfaces. On cross-section, the cortices appear congested and exhibit well-demarcated corticomedullary junctions. The collecting systems, ureters, and bladder are unremarkable. The urinary bladder contains approximately 10 mL of clear-yellow urine. PROSTATE: Unremarkable. MISCELLANEOUS: The wrists, ankles, and soles of the feet are incised and are unremarkable other than findings associated with previously mentioned external injuries. ‘The testicles are removed and cross-sectioned, and are unremarkable. The skin of the posterior aspect of the body is fileted with findings described in Evidence of Injury14-0319 WALTER, John MICROSCOPIC EXAMINATION Slide Key Slide #1-3: Heart Slide #12: Fracture, right posterolateral 8® Slide #4: Right lung rib Slide #5: Left lung Slide #13: Fracture, right paravertebral, 4" Slide #6: Liver rib Slide #7; Adrenal, kidney, spleen Slide #14: Fracture, right paravertebral, 6° Slide #8: Gastric wall nodule rib Slide #9: Cerebellum Slide #15: Fracture, left anterior, 2% rib Slide #10: Cerebral cortices Slide #16: Fracture left anterior, 4° rib Slide #11: Fracture, right posterolateral 3°! Slide #17: Fracture, left anterolateral, 5! and rib 6° ribs HEART: Sections show marked perivascular and interstitial fibrosis with associated myocyte hypertrophy. There are scattered epicardial and myocardial inflammatory cells predominantly consisting of lymphocytes, without evidence of acute or subacute myocardial injury. The fibrosis is concentrated and most severe within the left ventricular free wall (#1) and posterior interventricular septum (#3). LUNGS: Sections show congestion, scattered alveolar pigment-laden macrophages, scattered bacterial overgrowth, and a small focal collection of alveolar neutrophils within the lower lobe of the right lung. LIVER: Sections show moderate to marked steatosis, predominantly microvesicular, mild to moderate portal lymphocytic infiltrates, central passive congestion, and minimal cholestasis, KIDNEY: Sections show mild interstitial fibrosis and autolysis, ADRENAL GLANDS: No significant histopathologic changes. SPLEEN: No significant histopathologic changes. GASTRIC WALL NODULE: A section shows a collection of mesenchymal-type cells without significant atypia or abundant mitoses consistent with a benign tumor. BRAIN: No significant histopathologic changes. RIBS: Sections show fractures with surrounding hemorrhage consisting of individual red and indeterminate white blood cells and fibrin with necrotic bone fragments, bacterial overgrowth and autolysis. Iron stains, performed with adequate control shows a single possible hemosiderin-laden macrophage associated with one of the fractures within slide #17, ERBigdsToxicology Report EI Paso County Coroner's Office 2741 E. Las Vegas Street, Colorado Springs, CO 80906 Name: WALTER, JOHN Doctor: Emily Berry M.D. ‘719-390-2450 MAIN/719-390-2462 FAX Case #: 14-00319 Date Received: 04/22/2014 County: E! Paso Agency#: ‘Alcohols and volatiles: Analyte Specimen Result ETHANOL Femoral blood Negative Immunoassay screens (ELISA): Analyte Specimen Result AMPHETAMINE Urine Negative BARBITURATES Urine Negative BENZODIAZEPINE Urine Negative METABOLITES COCAINE! Urine Negative BENZOYLECGONINE FENTANYL Urine Negative METHADONE Urine: Positive METHAMPHETAMINE — Urine Negative OPIATES Urine Negative OXYCODONE Urine Negative THCCOOH Urine Negative TRICYCLIC Urine Negative ANTIDEPRESSANTS ZOLPIDEM Urine Negative GC-MS results (Qualitative) Analyte ‘Specimen Result IBUPROFEN Urine Present METABOLITES DIPHENHYDRAMINE Urine Present METHADONE Urine Present OLANZAPINE Urine PresentToxicology Report El Paso County Coroner's Office 2741 E. Las Vegas Street, Colorado Springs, CO 80906 749-390-2450 MAINI719-390-2462 FAX Case #: 14-00319 Date Received: 04/22/2014 Agency#: Name: WALTER, JOHN Doctor: Emily Berry M.D. County: £1 Paso Quantitative Results Analyte Specimen Result DIPHENHYDRAMINE Femoral blood 439 ng/m! METHADONE, Femoral blood 417 ng/mi OLANZAPINE Femoral blood 130 ng/mi Miscellaneous results Analyte ‘Specimen Result Sodium Vitreous 152 mmol/L Potassium Vitreous 13.5 mmoliL Chloride Vitreous 129 mmol Glucose Vitreous <20 mg/dl. BUN Vitreous 60 mg/d. Creatinine Vitreous 1.2 mgidL. Comments: wh Samal RBery AD, Reviewer Sighature Reviewer Signature