Cuyahoga County Medical Examiner's Office 11001 Cedar Avenue, Cleveland, Ohio 44106 IEDICAL EXAMINER'S VERDICT ‘Thomas P.Giton, MD, cal Earn ‘THE STATE OF OHIO, ss. CUYAHOGA COUNTY CASE NUMBER: IN2014-01919 Be it Remembered, That on the 13th day of November, 2014 information was given to me, Thomas P. Gilson, M.D., Medical Examiner of said County, that the dead body of a woman supposed to have come to her death as the resutt of criminal or other violent means, or by casualty, or by suicide, ‘or suddenly when in apparent health, or in any suspicious or unusual manner, (Sec. 313-11, 313-12 R.C. Ohio) had been found in Emergency Room, Cleveland Clinic in Cleveland of Cuyahoga County, on the 43th day of November, 2014 | viewed or caused to be viewed the said body at the Medical Examiner's Office. After the viewing ‘and making inquiry into the circumstances that caused the death of the said person, | obtained further information, to-wit: (CPD #2014-00359019) (CC #23195780). | aiso carefully examined or caused to be ‘examined the said dead body at 8:30AM on the 14th day of November, 2014 and | find as follows: to wit |, Thomas P. Gilson, M.D., Medical Examiner of said county, having diligently inquired, do true presentment make in what manner Tanisha N. Anderson , whose body was at the Medical Examiner's Office on the 44th day of November, 2014 came to her death. The said Tanisha N. Anderson was single, 37 years of age, a resident of Cleveland, Cuyahoga County, Ohio, and a native of Cleveland, Ohio: was of the Black race, and had brown eyes, black hair, ~ beard, -- mustache, was 66 inches in height, and weighed 251 pounds, Upon full inquiry based on all the known facts, | find that the said Tanisha N. Anderson came to death officially on the 13th day of November, 2044 in Emergency Room, Cleveland Clinic and was officially pronounced dead at 12:30 A\M., by Dr. Roth. There is history that on the evening of November 12th, 2014, Cleveland Police and Paramedics responded to a call of concem regarding the said Tanisha N. Anderson, 1372 Ansel Road. While in vicinity of 1374 Ansel Road, a physical altercation ensued, and legal intervention followed. This woman apparently became ill and collapsed, and treatment was administered. The said Tanisha N. Anderson was then transported to Cleveland Clinic where she was admitted to the Emergency Room at 12:11 A.M., in full cardiopulmonary arrest. ‘Advanced cardiac life support protocol and drug therapy were instituted, however, this woman failed to respond and was pronounced dead at the aforementioned time and date. The County Medical Examiner's Office was notified and Esposito Mortuary Services was dispatched. The said Tanisha N. ‘Anderson was then transported to the Medical Examiner's Office where an autopsy was performed. ‘That death in this case was the end result of sudden death associated with physical restraint in a prone position in association with ischemic heart disease and Bipolar disorder with agitation, with an other condition of obesity, and was homicidal in nature. Cause of Death: Sudden death associated with physical restraint in a prone position in association with ischemic heart disease and Bipolar disorder with agitation, HOMICIDE, Other Condition(s): Obesity. Tanisha N. Anderson fyp__—— MOD. (Name of Deceased) jahoga County Medical Examiner Page 1 of 1Cuyahoga County Medical Examiner’s Office 11001 Cedar Avenue, Cleveland, Ohio 44106 REPORT OF AUTOPSY ‘Thomas? Giton. MO. Wee Examiner THE STATE OF OHIO, ss. CUYAHOGA COUNTY CASE NUMBER: IN2014-01919 REPORT OF AUTOPSY OF: Tanisha N. Anderson ADDRESS: 1372 Ansel Road, Cleveland, Ohio |, Thomas P. Gilson, M.D., Medical Examiner of Cuyahoga County, Ohio, Certify that on the 14th day of November, 2014 at 9:10 AM in accordance with Section 313.13 of the Revised Code, of the State of Ohio, an autopsy was performed on the body of Tanisha N. Anderson. The following is the report of autopsy to the best of my knowledge and belief: This person was a female, single, aged 37 years, of the Black race; had brown eyes, hair, fair teeth, was 66 inches in height, weighing 251 pounds; a native of Cleveland, Ohio. ANATOMIC DIAGNOSE: |. Sudden death associated with A. Physical restraint with 1. Abrasions of left forearm, left and right knees 2. — Contusions of left forearm, left thumb, left lower leg, and left back B. Prone positioning C. Ischemic heart disease with atherosclerotic cardiovascular disease 1. Coronary atherosclerosis, moderate to severe i. Left anterior descending coronary artery with 70-80% atheromatous stenosis i. _Circumflex coronary artery with 50% atheromatous stenosis 2. to moderate myocyte hypertrophy 3. Hypertension (Clinical) 4. Arterionephrosclerosis, mild D. Bipolar Disorder, Type 4 (Clinical) 1. Recent hospital clinical evaluation with discharge (9/10/14-10/13/14) 2. Agitation (by terminal history) Ul. Obesity (Body mass index 40.5) UL Diabetes Mellitus (Clinical) IV. Cholelithiasis, gallbladder V. Therapeutic procedures ‘A. Indwelling endotracheal tube, intraosseous needles, central intravascular line, and peripheral intravascular line B. _ Electrocardiogram electrode pads C. Patient identification band D. Resuscitation chest compressions (Clinical) with cutaneous abrasion and sternal fracture Cause of Death: Sudden death associated with physical restraint in a prone position in association with ischemic heart disease and Bipolar disorder with agitation. HOMICIDE. Other Condition(s): Obesity. ~ David Keep, M.D. “0 ae) Of = (Name of Pathologist) Pathologist Si Tanisha N. Anderson EE See MD. (Name of Deceased) “Gdfahoga County Medical Examiner Page 4 of 1Case: IN2014-01919 County: Cuyahoga Name: Tanisha N. Anderson GROSS ANATOMIC DESCRIPTION EXTERNAL EXAMINATION: The body is that of a well-developed, well-nourished Black female, whose appearance is compatible with the reported age of 37 years. The body weighs 251 pounds and is 66 inches in length. The body is in full rigor mortis. Lividity is indeterminate. The skin temperature is cool The scalp hair is black curly and has a normal distribution. The conjunctivae are congested, the comeas are unremarkable, and the irides are brown. No petechial hemorrhages are present. The pupils are unremarkable. The earlobes are pierced bilaterally. The nose and mouth show no abnormalities. The teeth are natural and in fair condition. Remotely absent teeth are noted including a right lower incisor and Tight lower molar. The neck is of normal configuration, and there are no palpable masses. The thorax is symmetrical and normal in configuration. The breasts are of normal female configuration, and there are no palpable masses. The abdomen is Protuberant. The external genitalia are of normal female conformation. Multiple vulvar and perianal condylomas ure present. The extremities appear normal, and the joints are not deformed. All digits are present. The fingernails of the right and left hands have green and red nail polish. ‘The soles of the feet appear dirty. Thick callouses are present at the soles of the fect. There is adherent blue substance at the right and left sides of the chest in the area of the breasts. The skin is of normal pliabilty and texture and presents no significant lesions. There is ill-defined imegular scaring of abdominal skin and skin of the upper back. There is no icterus. SCARS AND IDENTIFYING MARKS: 1. Scar, large irregular and indurated involving right flank, right inguinal region, right perineum, and right buttock, 11° x 2”. 2. Scar, right volar wrist, 4” in length, 3. Scar, right anterior knee, 1” x 4, Tattoo, right lateral shoulder, faded with unknown depiction. EXTERNAL AND INTERNAL EVIDENCE OF RECENT THERAPY: 1. Indwelling endotracheal tube, present in trachea. a. Contusion, retroesophageal soft tissue, 1” x 14". 2. Intraosseous needle, left shoulder a. Four needle puncture wounds with drying artifact, left shoulder. Central intravascular line, left neck. a. Ecchymosis, soft tissue of left neck, 2 %" x 1”. Intravascular line, right antecubital fossa. Patient identification band, right wrist. Electrocardiogram electrode pads (2), left flank and central chest. Intra-osseous needle, right lower leg. Noo EXTERNAL AND INTERNAL EVIDENCE OF RECENT INJURY: 1. Red abrasions, posterior left forearm, proximal %4" x %4" and distal % x ¥" 2. Red abrasion and contusion, posterior left forearm/wrist, 1" x 34", a. Soft tissue contusion. 3. Red abrasion and contusion, anterior left distal forearmiwrist, 24" x 1%". a. Soff tissue contusion. 4, Red-brown contusion, left thumb pad, 1” x %’. 5. Red abrasion, left anterior knee, 14" x 4". 6. Red abrasion, right superior/antarior knee, ¥4" x 14". 7. Red abrasion, right inferior anterior knee, 1" x %’ 8. Contusion of soft tissue, left lateral lower leg. 9. Contusion of soft tissue, left posterior shoulder, 1 14” x 10. Rectangular area of skin discoloration with anterior red-gray border, left flank/chest, 4 14° x 4" 11. Red abrasions, central chest, measuring over an area 3 %4" X 1”. a. —_Contusion involving soft tissue of central chest, 14" x 4’, b. Fracture of sternum in the area of rib 3, The above injuries, once having been described, will not be referred to below. The remainder of the external examination of the head, neck, trunk, and extremities is unremarkable. Page 1 of 4Case: 1N2014-01919 County: Cuyahoga Name: Tanisha N. Anderson INTERNAL EXAMINATION: The bocy is opened by means of the usual *Y" and biparietal incisions. The viscera of the thoracic and abdominal cavities occupy their normal sites. The serosal surfaces are smooth and glistening. No fluids are present within the pericardial sac, right or tef! peural cavities, or abdominal cavity. There are no abnormal masses present. The diaphiagmatic leaves are normally situated. The ‘margins of the liver and spleen are in proper relationship to their costal margins. The weights of the organs are as follows and, unless specified below, show no additional evidence of congenital or acquired disease. Heart - 380 grams Right lung - 680 grams Left lung - 570 grams Spleen - 170 grams Liver - 2370 grams Right kidney - 160 grams Left kidney - 150 grams Brain - 1120 grams NECK: The neck organs are examines jn situ. An anterior neck dissection is Performed. Other than the ecchym2sis associated with the left neck soft tissue in the area of the central intravascular line, there is no evidence of injury or hemorrhage identified. The neck organs are excised en bloc and examined separately. The surface of the tongue and serial cross sections through the tongue show no gross abnormaiities. The larynx and trachea have a normal caliber and are free of obstruction. The laryngeal and tracheai mucosa is soft and tan. The paravertebral ‘musculature is unremarkable. The cervical spine, hyoid bone, and tracheal cartilage are intact. A posterior neck dissection is performed and no areas of injury or hemorrhage are identified. No cervical spine fractures are identified. CARDIOVASCULAR: Heart: The heart is normal in configuration. The coronary arteries have a normal anatomic distribution. The left anterior descending coronary artery has focal severe atherosclerosis with a maximal stenosis of 70-80%. The circumflex artery has moderate atherosclerosis with a maximal stenosis of 50%. The right coronary artery has minimal atherosclerosis. No thrombi are identified. The epicardium is smooth and glistening. There is a normal amount of epicardial fat and its distribution is normal, The great vessels enter and leave the heart in anormal manner. The cardiac chambers have a normal configuration. The septa are intact, and there are no congenital abnormalities. The myocardium is of normal consistency and appearance. The left ventricle is 1.2 om thick, septum 1.3 om thick, and right ventricle 0.4 cm thick, respectively. The heart valves are thin, pliable, and delicate, and are free of deformity. Valve circumferences are as follows: tricuspid valve = 13 cm, pulmonic valve = 7 om, mitral v:'ve = 9.5 cm, and aortic valve = 7 cm. Aorta and its major branches: The aorts and its principal branches are patent throughout. There are no thrombi, areas of erosion, of zones of significant narrowing present. Venae cavae and their major tributaries: The superior and inferior venae cavae and their major tributaries are patent throughout. No areas of extrinsic or intrinsic stenusis are present. RESPIRATORY: The major bronchi have a normal caliber and are free of obstruction. The right and left lungs have a normal lobar configuration. The visceral pleura is smooth and glistening and slightly mottled with black streaks. There are no subpleural emphysematous bullae. The pulmonary arteries are free of emboli and thrombi. There is moderate to marked pulmonary congestion and edema. The lungs are subcrepitant throughout. The parenchyma is unremarkable. RETICULOENDOTHELIAL: The spleen has a normal configuration. The capsule is blue-gray and smooth, without areas of thickening. On section, the splenic pulp is of normal consistency and appearance. No abnormal lymph nodes are encountered. DIGESTIVE; The esophagus is free of lesions. The stomach has a normal configuration. The serosa is smooth and glistening. The wall is of normal thickness and the mucosa is thrown into rugal folds. There are no areas of ulceration. The ‘stomach contains approximately 90 ml of brown-gray fluid. The duodenum is free of Ulceration and other intrinsic lesions. The remainder of the small bowel, the colon, and the rectum are normal in appearance. The appendix is present and is unremarkable. Page 2 of 4Case: IN2014-01919 County: Cuyahoga Name: Tanisha N. Anderson HEPATOBILIARY: Liver: The capsule is smooth and glistening. The liver configuration is normal. ‘Multiple cross sections through the liver reveal a normal lobular pattern and acute congestion. Gallbladder: The gallbladder is of normal size and configuration. The wall is thin and the mucosa is bile-stained. The gallbladder is packed by multiple ovoid, yellow- green to black mixed gallstones. It contains approximately 2 ml of bile. PANCREAS: The pancreas is firm and normally lobulated. Multiple cross sections through the pancreas reveal normal tan-pink parenchyma without intrinsic lesions. GENITOURINARY SYSTEM: Kidneys: The right and left kidneys are simitar. The capsules strip with ease to reveal milily granular subcapsular surfaces. The renal arteries and veins are patent and free of stenosing lesions. On section, the renal cortices are of normal thickness and the cortico-medullary demarcations are distinct, The medullae are unremarkable. The pelvo-calyceal systems are normal in appearance. The ureters are unremarkable. Bladder: The bladder is of normal configuration. The mucosa is intact and free cf ulcerations or other lesions. It contains approximately 15 ml of urine. Gynecological system: The vaginal mucosa is smooth, tan, and free of lesions. The cervical os and cervical mucosa are unremarkable. The endometrial cavity is of normal configuration and the endometrium is tan-pink. The myometrium is normal, There are no parametrial lesions. The fallopian tubes are thin-walled, pliable, and free of lesions. The ovaries are symmetrical and unremarkable. ENDOCRINE SYSTEM: No abnormalities are present in the pituitary, thyroid, or adrenal glands. MUSCULOSKELETAL: The appendicular skeleton shows no abnormalities. The exposed musculature is unremarkable. HEAD/BRAIN: The scalp shows no evidence of contusions or galeal hemorrhages. ‘The skull is intact. The dura is smooth and glistening. The convexities of the cerebral hemispheres are symmetrical. The leptomeninges are thin and transparent The subarachnoid space does not contain any hemorrhage. The cerebrum presents normal convolutions, with no flattening of the gyri or deepening or widening of the sulci. There is no evidence of subfalcial, uncal, or cerebellar tonsillar herniation present. The major cerebral arteries show no significant atherosclerosis or congenital anomalies. The roots of the cranial nerves are unremarkable. Serial coronal sections through the cerebral hemispheres show a grossly normal cortical ribbon and underlying white matter. The basal ganglia and diencephalon show no gross abnormalities. Serial cross sections through the brainstem and sagittal ‘sections through the cerebellum fall to show any gross lesions or abnormalities. The ventricular system is symmetrical and of normal size and configuration. After ‘removal of the brain, the base of the skull does not demonstrate any fractures. SPINAL CORD: The spinal cord is smooth, white, and glistening, and serial cross sections through the spinal cord show no gross abnormalities. Drs. Erica Armstrong and Thomas Gilson were present during the autopsy. MICROSCOPIC DESCRIPTION HEART: Mild to moderate myocyte hypertrophy of left and right ventricles Sections of the left anterior descending coronary artery shows severe atherosclerosis ‘Sections of the circumflex artery show calcific. atherosclerosis Page 3 of 4Case: IN2014-01919 County: Cuyahoga Name: Tanisha N. Anderson LUNGS: LIVER KIDNEY: BRAIN: SOFT TISSUE OF LEFT WRIST: SOFT TISSUE OF LEFT LEG: SOFT TISSUE OF LEFT BACK/SHOULDER: Pulmonary congestion and edema Increased intra-alveolar pigmented macrophages Focal interstitial flbrosis with chronic inflammation and pigment laden macrophages Extracellular intra-alveolar bacterial colonies present Patchy mild interstitial fibrosis and emphysematous changes Polarizable formalin pigment and rare intra-alveolar extracellular polarizable foreign material Acute sinusoidal congestion Occasional hyperlobated intrasinusoidal neutrophils noted Autolysis Mild fibrointimal hyperplasia and medial thickening of ‘small arteries No significant pathologic abnormality Extravasation of blood into fibroadipose tissue Extravasation of blood into fibroadipose tissue. Extravasation of blood into fibroadipose tissue aD) LY [ann yD LLfis— David Keep, M.D. Date Page 4 of 4ology Laboratory Report Cuyahoga County Regional Forensic Science Laboratory 11001 Cedar Avenue, Cleveland, Ohio 44106 Final Report cuyaHoGa county REGIONAL FORENSIC SCIENCE LABORATORY Page 1 of 4 Case Number: —1N2014-01919 Report Date: Friday, December 19, 2014 Name : Tanisha Anderson Receipt Date: Friday, November 14, 2014 Agency Cuyahoga County (CCMEO) Pathologist: DKEE - David Keep - M.D ‘Specimen Received J 21 bine Format od ct come a0 7 iets U-trer orem Sage Re-tengem Sage v-uine Vt -vteous Humor ‘COMMENT, EXE a Drug Group/ciass Result ‘Quantitation “Analye(s) Acetaminophen Screen None Detected ‘See Page 4, Group 8 Salicylate Screen None Detected See Page 4, Group 10 GREE Drug Group/Class Result ‘Quantitation ‘Analye(s) Volatile Screen & Confirmation None Detected See Page 4, Group 1 Acid Neutrals by GCIMS None Detected ‘See Page 4, Group? Opiate ELISA Screen None Detected ‘See Page 4, Group 7 Basic Drugs by GC/MS Positive See Page 4, Group 8 Caffeine Positive Citalopram Positive Cotinine Positive Diphenhydramine < 0.10 mgf. Nicotine Positive Quetiapine Metabolite Positive ‘Amphetamine ELISA None Detected ‘See Page 4, Group7 Barbiturates ELISA Screen None Detected. See Page 4, Group 7 Benzodiazepines ELISA Screen None Detected Ste Page 4, Group7 Cannabinoids ELISA Screen None Detected ‘See Page 4, Group 7 Carisoprodol ELISA Screen None Detected ‘See Page 4, Group7 Cocaine Mtb. ELISA Screen None Detected ‘S00 Page 4, Group 7 Fentanyl ELISA Screen None Detected ‘Seo Page 4, Group7 Methamphetamine ELISA Screen None Detected ‘See Page 4, Group 7 ‘Oxycodone ELISA Screen None Detected See Page 4, Group7 Phencyclidine ELISA Screen None Detected Seo Page 4, Group7 Tricyclic Antidepressants ELISA Screen None Detected ‘See Page 4, Group 7 Methadone ELISA Screen None Detected ‘S00 Page 4, Group 7 ‘Sent to Reference Lab NMS **** See Page 4, Group 20 aToxicology Laboratory Report ‘CUYAHOGA Cuyahoga County Regional Forensic Science Laboratory couNTY 11001 Cedar Avenue, Cleveland, Ohio 44106 fowe Final Report SCIENCE LABORATORY Page 2 of 4 Case Number: —_IN2014.01919 Report Date Friday, December 19, 2014 Name : Tanisha Anderson Receipt Dat Friday, November 14, 2014 Agency : Cuyahoga County (CCMEO) Pathologist: DKEE - David Keep - MD. Drug Groupiciass Result ‘Quarstaton ‘Analyte(s) Sent to Reference Lab NMs ‘See Page 4, Group 20 Full Toxicology Ns cl CRIs a ‘Drug Group/Class Resutt ‘Analyte(s) No Test Performed aa EI Drug GroupyClass Result ‘Quantitation ‘Analyie(s} No Test Performed _ Drug Group/Class Result ‘Quantitation ‘Analyte(s) No Test Performed ied PER aCce ees Drug GroupiClass Result ‘Quanttabon ‘Analyte(s) No Test Performed = ‘Drug Group/Ciass Result ‘Quantitation ‘Aralyte(s) No Test Performed ae Drug Group/Class Result ‘Quantitation ‘Analyte(s) Glucose/Ketone bodies None Detected Basie Drugs by GC/MS Positive See Page 4, Group 8 Quetiapine Metabolite Positive Citalopram Positive PER aes Drug GroupiClass Result ‘Quantitation ‘Analyte(s) Clinical Chemistry Positive ‘See Page 4, Group 12 aeToxicology Laboratory Report ‘CUYAHOGA Cuyahoga County Regional Forensic Science Laboratory {4 county 11001 Cedar Avenue, Cleveland, Ohio 44106 REGIONAL Final Report a LABORATORY Page 3 of 4 Case Number: —_ N2014-01919 Report Date: Friday, December 19, 2014 Name : Tanisha Anderson Date: Friday, November 14, 2014 Agency : Cuyahoga County (CCMEO) Pathologist: | DKEE - David Keep - M.D PER er ‘Drug Group/Class Result ‘Quantitation ‘Analyte(s) Clinical Chemistry Positive ‘See Page 4, Group 12 Sodium (mmol/L) (CL.= 95.45%) | 145 +2 mmoln. Potassium (mmol/L) Not Done Chloride (CL.= 96.46%) | 19622 mmovL Calcium (CL. = 95.45%) | 1.500.068 mmol Magnesium (CL. =95.45%) | 0.70+0.05 mmo Glucose (CL. = 95.45%) 100+ 5 mg/dL. Lactate (CL = 98.45%) 1721 mmol. Urea Nitrogen (CL. = 95.45%) 1042mgfdL. Not DoneToxicology Laboratory Report Cuyahoga County Regional Forensic Science Laboratory 11001 Cedar Avenue, Cleveland, Ohio 44106 Final Report Page 4 of 4 1) VOLATILES: Acsaldehyte, Accone,Actnlet, Butane Chlorfem, Dicloranebane, Eiko, iy Ace, Formsldyée,kopropal Mabie, ‘Mebuanol, arc", Propane, Toase™. “ETHANOL, ACETONT, ISOPROPANOL, thé METHANOL CONFIRMATIONG) by aeralive GC con {nde aernatve spectent. METHANOL i difreniaed fam FORMALDEHYDE by Carinry (Quailate) 2 ea ntti tte err Sc it etree cto ett se rte es en FSS nce ren Pt ce amt err Bouin waonaneeomaemens ama 3) CARBONMONOXIDEY Cutcshemoglbi) by CO-Oxtmetry: Carbon Monoxide Metkemaglebia, Hanoy; CARBON MONOXIDE CONFIRMATION by Specrophotomety der Mlcroaion 9 GLYCOL: Foyle Cyc, Mopyene Glee Seromod and Confirmed by GOS. (CYANIDE Screened and Quatied by Clorimety. © EMITESCREEN: SYMPATHOMIMETIC AMINES (SMA) (get= Amphetamine): BENZODIAZEPINES (Tug Onaropan ‘COCAINE Hiyet= Beaznyiecgmne cocaine meibalic) CANNABINOIDS (Tuget>L-eor--3-THC-COOH i marjuana meet, (OPIATES (Tage Maphin), PHENCYCLIDINE user Phonyeig). 2 HIS ome mnie in SHEEN Tin at epee See Ow Hua ena ube = ah hae fe csc lin fate es hep ‘see c= fa icagee e 3 = Facet eck ales be Nea wetness 5) BASICDRUGS ty GCMs (Quumitton nd Confirmation): Amann, Aniipyine Amonapine Amphctmine, Atvpae, Beszbopins Sromphexcanine, Dupivaeains, Buprepion, Bupropion Maal, Busooe, Callen, Cabnenamine,Cherphanippericine Chop urine, catrpremaains Chale, lenipraize, Seapine, Cometinere, Coane, Calewe,Coee and ntababtex Cnn Cycle, Cyeiben ape, Denllitrerpen, Deseamire Bean (Blrizapride, Deane Gian pranine Demet Gazal Des aisrse, Dem tyne, Dement, Dacepam, Deshpreien ‘Dilhatdanine, Diepsranide Ditazea, Doepn, Dnyanine,Seganne me! exe, Ephedneanudaeedene, Feneraine, Peay Fusco, ‘Fvoraning Giitesn, Hoh, Mydecodane, Hyena, iprnis, ketaninn, Lavcanesay Leora Licoane mb SBSH Lope, pie, Mocine Mepene, Mcphenteine, Msscsin, Metidene,Mthadae inary nb (EDDE), Methadone wandary mb (EDN, Malan Se yito- Nerrepeyphen, ‘Gryends,Ppnvene, Poet, Patz, Penonin, Perpenzine Phenyehdng bets Ponatilaae, Prenaniae heedenetiss, leneeeee, ‘Phartamine, Peaylpepantanie Phenyclocmine, Procane,Pronsiaie, Propoxyphene, raprnaa Petipjing Feudecbetine Pytmnc Gostayng, ‘Guinidns, Gein, Serra, Theda, Tramadc,Trayljpromine, Hazdone, Irinerypbe@y.Trinipemine, Venainns Vanpeni 2opscon 9 ACETAMINOPHEN SCREEN: Aecaninophen ly Colernetry (Quaiatve. 19) SALICYLATE SCREEN: Saleyate (pra by Coerimary (Qultatvg, SALICYLATE CONFIRMATION by Gas Chromatograpy. 1) XANTHINES by Gos: Acuimicohen, ote 12) CLINICAL, CHEMISTRIES (CHM: Ketones, pe, Specie Grit, and Fledrles (Sodium, Petaian, Clade, TCO2, Goose, ea Ceti 13) COCAINE CONFIRMATION by GOMS: Alyehoteganine metyl exer, Renzoyleegaine, Cone, Coaeylene, Egonne ay eda Zepmine mals eer, 14) CANNADINOIDS Wy GOMS: Cumsbinoids gf; meg: D9-THC, 1-09 fmaruan metabolite, 11 D9-THC-COOH (aman tboe), TOTAL tae DETHCCOOH @marjenameialte, 19) OPIATES GCMs ag/atys Nein €-Aeynphine (on mesboltd), Coking Hykeoxdone, Diycdeng yeoman, Neots’ Ongar: Srymapne TOTAL OPES COnieib alae lowed Crass Oo fe 16 BENZODIAZEPINE CONFIRMATION by GCS: Algruzlan/ metabo, Dienpen/ metabolites, Clonsapam, Lae, Midtzslan nebo, Tirta. 1) SYMPATHONIMETIC AMtIYRS CONFIRMATION by GOMIS tral (/n): Amemadng, Aphting, bee heathens, MDEA, Meterpheaming, Metilenecoxyepbetanine DA), Nether ecoeynethanpheanine (MDMA), Phatemine Parybreperlanine, Pecos 1) GuIBty COMS (g/L): Ganmeptronybuyri sell gamma byron. 19) PRNTANYL by GODS (ogni: Fenny Sufeuani, Aten, 20) SENT OUT TO REFERENCE LABS: Sys Cambicods 8 Sythe Cebnanes Epis, 7min Fonz, Fnraspam 1 asin, LD, ‘Neen, ee, Palin, Riprdce, Tptan, Wars, Vale Aci, HEAVY METAL SCRIEN: (Aman. Aris Lend Bag, a, Bea, ‘Meron, Seles oy er gene lied sow {BY REQUEST ONLY; ABBREVIATIONS: POs-Postine, NEG-Negatv; UNS~Spectnen viiabe fo tring: NTDN-Not Done ONS-Catty inset ie sly CHER 7=CtnelChemiary, ces han; >~qretr ha: URL= Lome sparing ime CLs = Goce Love UNITS FoR VOCATHLAS: 1c0:mp/al=0.00 if 0.100 ghe UNITS: 1 ng 1000 gg = 000 rg, | cetiy thatthe specimen identified by this case, oumber INZ014-01019 have heen handled and analyzed in accordance wih all applicable recurerens, The ulin is report ate tote fers fested For pupoaes of dancalon anc cate Facing he Taecolg) Lab te case numbers exclsiey” "Name s subject fo change Based on receipt of frmaton. Ths eport shal ot be reproduced extant Ri, ious \wtten approval of the Cuyanega County Regional Forensic Seehoe Laboratory Chiet Forensic Toxicologist asda E hex br —— 1220/1 Harold E. Schueler, Ph.D.Phone: (215) 657-4900 "Fax: (216) 657-2072 TABS ‘emai: nms@nmsiabe.com ‘Robert A Mccleberg, PID, F-ABFT, DABCC-TC, Laboratory Dector NMS Labs CONFIDENTIAL, ‘3701 Welsh Read, PO Bax 499A, Willow Grove, PA 19090-0437 Cotass Toxicology Report Patient Name ANDERSON, TANESHA Patient ID 1N2014-01919 Reportlssued 12/22/2014 19:39 en ae Last Report Issued 12/22/2014 13:00 ages7Y DOB OLaer7 Gendor Female To: 10088 Cuyahoga County Medical Examiner Workorder 34336974 Attn: Dr: Harold Schueler 11001 Cedar Avenue/Tox 5 FL eae Cleveland, OH 44106 Result Units Matrix Source Positive megimL 001 - Femoral Blood Cotinine Positive ngimL 001 - Femoral Blood Citalopram /Escitalopram 820 ngimL 001 - Femoral Blood Quotiapine 520 nim. 001 - Femoral Blood Risperidone 19 ngimL 004 - Femoral Blood ‘2-Hydroxytisperidone 7 ngimL 001 -Famoral Blood Risperidone and 9-Hydroxyrisperidone - 960 ‘ngimL 001 - Femoral Blood Total Diphenhydramine 100 gi 001 - Femoral Blood See Detailed Findings section fr addtional information Testing Requested: Analysia Code Description ame Peatmariem Toxeaiogy- Expanced, Bisod (FOrEnS) ‘Specimens Received: 1D TuberContainer Volume! Collection Matrix Source Miscellaneous Mass Date/Time Information DOT Gray Top Tee ‘STEmL Wot Given Fomoral Bod ‘Al sample volumesiweights are approximations. ‘Specimens received an 12/10/2014,CONFIDENTIAL Workorder 14316974 N MS Chain 11773968 Patient ID N201401919 (Cass Page 208 Detaled Findings: Analysis and Comments Result Units ti ‘Specimen Source: Analysis By Coton — neg“ —~ G0} Femoral Blood ——-LeTOR-M Cotnine Pestive nm 1000 O0T-Fameral Blood ——_LOTOR NS Calapan /esctalopem 320 oink 50.0 -Femoralsiond LOMAS os 20 nom §0——O01- Femoral Blood «LOANS Repetto 8 rom. 10.01 Femorl Blood LOANS AS SHvdomreperaone 77 gm. 10—=—t Fecal Blood «LOM RRapeidone and. 60 safe 001-Fenorl Blood = LOMSMS Prcronynaperone- Tota Dpnenhycrmine 400 nm 5.—=—t Femoral Blood LOSS 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: ‘S-Hydroxyrisperidone (Risperidone Metabolite) - Femoral Blood S-Hydroxyrisperidone is a major active metabolite of risperidone, an entipeychotic agent. Risperidone and hydroxyisperidone ere approximately equi-effective, therefore, the clinical effects result from the combined ‘concentrations of rsperigone and 8-nydroxyrisperidone. The rate of metabolism to &-hydroxyrisperidone is ‘subject to genetic predisposition, meaning that extensive metabolizers (approximately 82% of the population) ‘convert risperidone rapidly to 9-hydroxyrisperidone, while poor metabolizers convert at a much slower rate. The [pharmacokinetics of the sum of nsperidone plus 9-hydroxyrisperidone is similar for both extensive and poor ‘metabolzers with an overall meen elimination nalf-fe of approximately 24 hours (see reference cornment for Risperidone and &-Hycroxyisperidane - Total) Caffeine (No-Daz) - Femoral Blood: Caffeine is xanthine-derived canta nervous system stimulant It also produces diuresis and cardiac and respiratory stimulation. Itcan be readly found in such items 9s coflee, tea, sof crnks and chocolate. As & 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 (Gitalopram I Escitalopram (Celexa® / Lexepro®) - Femoral Blood: Citalopram (Celexa) is @ selective serotonin rouptake inhibitor (SSRI) thet increases brain levels of serotonin, ‘chemical that is thought tobe liked to mood, emotions, and mental stato. The drug is indicated for use as an ‘antidepressant. Citelopram isa racemic mixture of S- and R-enantiomers and the S-enantiomer is more potent than the R-enantiomer. Steady-state serum or plasma levels from palients on a dally regimen of 30 10 60 mg of citalopram range from 9 - 200 gmt. ‘Adverse effects due to acute overdosage with 800 mg or more of ctalonram may include EKG abnormalities ‘nd seizures. in pastmortsm blood, concentrations in documented fatalites Involving otalopram have ranged from 3400 - 11000 ngim. Escitalopram (Lexapro) is the S-enantiomer of racemic citalopram and t also is indicated for use in the ‘treatment of depression. It binds with greater afiity to the serotonergic transporter than the R-enantiomer Steady-state peak plasma levels from patents on regimen of 10 or 30 mg/day of escitalopram were reporiod as 21 and 64 ng/mL, respectively, and occur at approximately 4 hours post dose, ‘This testis not chiral specific; therfore, citalopram andior escitalopram may be present, odCONFIDENTIAL Workorder 14316974 N M S Chain 1773968 Pationt iD IN2014-01919 Tes] Page 3 0f 5 Reference Comments: 4. Cotinine (Nicotine Metabolite) - Femoral Blood: Cotinine is @ metabolite of nicotine and may be encountered in the fus and tissues of an individual as a resuit ‘of tobacco exposure, ‘Anabasine is @ natura product occurring in tobacco, but notin pharmaceutical nicotine and a separate test for ‘anabasine in urine can be used to distinguish tobacco from pharmaceutical nicotine Use, “The reported qualitative resul for this substance was based upon a single enelysis onl. If confirmation testing Is required please contact the laboratory. 5. _Diphonhydramine (Benadryl®; Ingredient of Benylin and Panadol; Nytol; Unisom) - Femoral Blood: Diphenhydramine is an anthistamine with sedative and anti-ometic effects, Its rapidly absorbed following oral ‘administration; nowever, tis frequently given IV. Patients taking this mecicalion are usually wamed against the ‘operation of complicated machinery, because ofits song sedative effects Following a single 50 mg oral dose of diphennydramine, peak plasma concentrations at 2.3 hr averaged 66 ‘Agim. ‘Signs and symptoms of acute diphenhycremine toxicty include tremor, seizures, fever. respiratory depression ‘and cardiac ahythmias. The average blood diphenhydramine concentrations reported in fetal overdoses were 1400 ngimL in infants, 4400 ngiml in children and 15000 ng/mL in adults. ‘The blood to plasma concentration ratio for diphenhydramine is approximately 0.80. 6 Quetiapine (Seroquel®) - Femoral Blood Quetapine is an antipsychotic compound approved by the FDA for the management ofthe manifestations of Bsyehotc disorders including schizophrenia. Itis a structural analogue of clazapine that addresses tho positve ‘and negative symptoms of schizophrenia, but does so with few of te traditional side effects of conventional or ‘other atypical antipsychotic medications. ‘Steady-state peak (1.0 101.5 hr plasma levels following a TID daily regimen: 225 mgiday - 288 ng/mL. 480 maiday - 698 ng/mL 750 malday - 828 ngimL “The prasma hall-ife is approximately 6 hr. ‘After an apparent quetiapine overdose, a postmortem blood concentration of 170000 ng/mL was reported, In a ‘case of suicide with quetiapine and 4 other drugs, postmortem cardiac blood contained 49000 ntl of quetiapine. 7. Risperidone (Risperdat®) - Femoral Blood: Risperidone is an atypically structured antipsychotic agent. The inital ecommended dosage in adults fe 1 mg twice daily Risperidone ie metsbolized inthe ler to 8.hydroxyrsperidone, a major active metabolite. Risperidone and 9- hycroxyrisperidone are approximately equaly active. Consequently, the clinical effet of the drug resus fom the combined concentrations of risperidone plus 8-hydroxyrisperidone, The rale of metabolism to S- hhyaroxyrispericone is subject to genetic predisposition, meaning thal exiensive motabolze's (approximately {82% of the population) convert nisperidone rapily to &-hydroxyrisperidone, while poor melabolizers convert at ‘a much slower rate. The pharmacokinetics of the sum of risperdone plus S-hydroxyrispericone s similar for ‘both extensive end poor metaboizers with an overall mean elimination halite of approximately 24 hr Risperidone and &-hydroxyrsperidone are approximately equally effective, therefore, the sum of the ‘concentrations is pertinent Mean steady-state plasma levels forthe total acve moiety folowing daily regimens: 2 mghday - 14 ngiml. (Risperidone + Metabolite) E mgiday - 45 ngiml (Rispericone + Metaboite) ‘0 mgitay -73 ng. (Risperidone + Metabolite) ‘6 mgiday - HO ng/mL (Risperidone + Metabolite) : aighomen ee ANMS Soiree rel llincrern ee THES Page 4of5 Reference Comments: 8. Risperidone and 8-Hycroxyrisperidone - Total (Total Active Moiety) - Femoral Blood: Mean steady-state plasma levels forthe total active moiety (Risperidone + Metabolite) following daly regimens: 2 mplday - 14 rolmL. mg/day - 45 ngimL. 10 mglday -73 ng/mL. ‘Bmglday - 10 ng/mL. Unless alternate arrangements are made by you, the remainder ofthe submitted specimens wil be discarded one (1) year ‘rom the cate ofthis report and generatad data will be discarded five (5) years from the dale the analyses were Performed, ‘Workorder 14316974 was electronically signed on 12/22/2014 12:03 by: Avon [, Cal bar ‘Susan Crookham, Certifying Scientist Analysis Summary and Reporting Limits: Allo the following tests were performed for this case. For each test, the compounds listed were included inthe scope. The Reporting Limi isted for each compound represents the lowest concentration of the compound that will be reported ae boing postive. Ifthe compound is listed as None Detected, itis not present above the Reporting Limit. Please refer tothe Positive Findings section ofthe report for those compounds that were Kentified as boing present. ‘Acods 520218 - Citalopram Confirmation, Blood (Forensic) - Femoral Blood Analysis by High Performance Liquid Chromatography! ‘TendemMass Spectrometry (LC-MS/MS) for Compound Limit ‘Compound ‘Rot Limit Citelopram / Escitalopram 5.0-ngim. ‘Acode 521128 - Quetiapine Confrmation, Blood (Forensie) - Femoral Blood -Analysis by High Performance Liquid Chromatography! Tandem¥ass Spectrometry (LC-MS/MS) fr: ‘Compound, ot Limit ‘Compound Limi Quetiapine 50 ngim. ‘Acode 524368 - Risperidone and Metabolite Confimmatin, Blood (Forensic) - Femoral Blood Analysis by High Performance Liguid Chromatograohy/ ‘TandemMass Spectromety (LC-MSIMS) for. Gormpouns Rot Limit ‘Compound Rot Limit S+Hydroxyrisperidona 1.0 agit Risperidone and 9- NA Risperidone 1.0 ngimt Hiydtoxyrisperidone - Total ‘Acode 524418 - Diphenhydramine Confirmation, Blood (Forensic) - Femoral Blood Analysis by High Performance Liquid Chromatography! TandemMass Spectrometry (LC-MS/MS) for ‘Compound Bt Limit Gompouns Bot Limit Diphenhydramine 50 night. ‘Acode 80528 - Postmortem Toxicology - Expanded, Biood (Forensic) - Femoral Blocda CONFIDENTIAL Analysis Summary and Reporting Limi Workordor Chain Patient 1D Page 5 of 5 “Analysis by Enzyme-Linked Immunosorbent Assay (ELISA) for: ‘Compound RotLimit Barbiturates: 0.040 meg. Cannabinoids 40 ngimL. ~Analysis by Headspace Gas Chromatography (GC) for: ‘Compound Rot Limit ‘Acetone 50 mgféL, Ethanol sO mgiat. Analysis by High Performance Liquid Chromatogrephy ‘Compound Salicylate ‘Compound 'soproparol Methanol 14316074 11773365 1N2014-01919 Rot Limit 420 megim ‘Rot Limit 5.0 mold 5.0 mgidL Time ofFlight-Mass Spectrometry (LC/TOF-MS) for The following is a general list of ompound classes included In this screen. The detection of any specific analyte is cancentration-dependent. Note, nol al known analytes in leach specified compound class are included. Some specific analytes outside these classes are also inched. For a detaied list ofall analytes and reporting limits, please contact NMS Labs. Amphetamines, Anticonvulsants, Antidepressants, Antihistamines, Antipsychotic Agente, Benzodiazepines, CNS. ‘Stimulants, Cocaine and Metaboites, Hallucinogen, Hypnosedatives, Hypoglyoemics, Muscie Relaxants, Non Steroidal Ant-nflammatory Agents, Opiates and Opioids vad