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DEATH INVESTIGATION SUMMARY

Case Number: 2013-06715 VARELA, OMAREE


County Pronounced: Bernalillo Law Enforcement: APD Criminalistics Agent: Chad Stuart Date of Birth: 2/3/2004 Pronounced Date/Time: 12/27/2013 5:32:00 PM Central Office Investigator: Daniel Wasko Deputy Field Investigator: Daniel Wasko

CAUSE OF DEATH Blunt trauma

MANNER OF DEATH

Homicide

Odey Ukpo MD
Forensic Pathology Fellow

Sam Andrews MD FRCPC


Associate Medical Investigator
All signatures authenticated electronically Date: 3/7/2014 4:50:48 PM

Printed: 3/25/2014 11:45:49 AM

Report Name: Death Investigation Reporting Tool

Death Investigation Report Page 1

DECLARATION The death of VARELA, OMAREE was investigated by the Office of the Medical Investigator under the statutory authority of the Office of the Medical Investigator. I, Sam Andrews MD, FRCPC a board certified anatomic, and forensic pathologist licensed to practice pathology in the State of New Mexico, do declare that I personally performed or supervised the tasks described within this Death Investigation Summary document. It is only after careful consideration of all data available to me at the time that this report was finalized that I attest to the diagnoses and opinions stated herein. Numerous photographs were obtained along the course of the examination. I have personally reviewed those photographs and attest that they are representative of findings reported in this document. This document is divided into 10 sections with a final Procedural Notes section:
1. Summary and Opinion 2. External Examination 3. Medical Intervention 4. Postmortem Changes 5. Evidence of Injuries 6. Internal Examination 7. Neuropathology 8. Microscopy 9. Radiography 10. Peer Review

Should you have questions after review of this material, please feel free to contact me at the Office of the Medical Investigator (Albuquerque, New Mexico) - 505-272-3053.

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Report Name: Death Investigation Summary

Death Investigation Report Page 2

Case Number:

2013-06715

Summary Opinion
Medical lnvestigator Trainee Odey Ukpo MD

VARELA, OMAREE

Medical Investigator Sam Andrews MD

SUMMARY AND OPINION


According to the initial report given to the Office of the Medical Investigator by Detective English of the Albuquerque Police Department, the decedent's mother reports that on December 27, 2013, the decedent was on a toy horse and was pushed from the horse by his 3 year old sibling, striking his head on the floor and losing consciousness. She stated that she called her husband, the decedent's step-father, who was not at home. Apparently, he placed the decedent in the shower to attempt to revive him. His mother then called his pediatrician who advised her to call Emergency Services. Subsequent conversations with the step-father revealed that he was at home and heard the decedent's mother "beating him". Additionally, the mother told police that she knocked him into a dresser and he fell to the floor. While on the floor she stomped on him twice and kicked him in the abdomen. The decedent was taken to the University of New Mexico hospital emergency room, where resuscitation was attempted for 30 minutes without success and he was pronounced dead at 17:32 hrs on 12/27/2013. Review of the decedent's medical records available to us at the time of this report showed that he was born at 34 weeks gestation by Cesarean section at the Cibola General Hospital while his mother was incarcerated at the Grants County Women's Prison. He had been diagnosed with mild developmental delays, attention deficit hyperactivity disorder, and post-traumatic stress disorder. There had been 9 referrals to the Children Youth and Family Department (CYFD) and two were substantiated. One referral came in 2012 when the decedent reported to school personnel that his mother had hit him on the head with either a bat or phone, and had hit him on the leg with a belt. This referral was substantiated for physical abuse by and unknown perpetrator. At autopsy, there were contusions (bruises) of the chest, arms, legs and tongue; abrasions (skin scrapes) of the face; a healing laceration (skin tear) of the scalp (left parietal scalp); and hemorrhage (bleeding) into the muscles between the ribs (intercostal hemorrhage), into the soft tissues of the back, into the diaphragm (muscle that separates the chest and abdominal organs), into an abdominal wall muscle (right internal oblique muscle), into the abdominal cavity (hemoperitoneum), into the soft tissues around the pancreas and left kidney; and on the outer surface (serosa) of the bowel. On the chest were discreet injuries consistent with thermal injuries (burns). Microscopically, the chest wounds show features suggestive of a thermal injury, the scalp laceration showed evidence of healing (approximately days old), and there was acute inflammation and hemorrhage into the tongue. Forensic odontologic (dental) analysis of the bruise on the right forearm was suggestive of a small human bite. Forensic Neuropathology Consultation showed mild cerebral edema (swelling of the brain). A skeletal survey showed no osteologic (bone) abnormalities. Postmortem toxicological testing on the blood was negative for alcohol and drugs of abuse. Postmortem vitreous (eye) fluid electrolytes (a measure of salt-water balcance) was normal. The decedent was physically an appropriately developed boy with injuries at different stages of healing with no evidence of significant underlying natural disease. This pattern is consistent with a history of abuse. There were impact sites to the trunk associated with bleeding into the soft tissues of the abdomen and into the abdominal cavity. A significant amount of blood was lost, accounting for approximately 25% of his total blood volume. A definitive bleeding source could not be identified and, therefore, likely came from small vessels in abdominal organs or soft connective tissue. After significant blood loss, delivery of oxygenated blood to the brain would decrease resulting in cerebral edema.

Cause Of Death:

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Case Number:

2013-06715

External Examination
Medical Investigator Trainee Odey Ukpo MD

VARELA, OMAREE

Medical Investigator Sam Andrews MD

External exam date time: Authority for examination: ID confirmed at time of exam: Means used to confirm identity: Other verification means: Location of orange bracelet: Name on orange bracelet: Other name on orange bracelet: Location of green bracelet: Name on green bracelet: Other name on green bracelet: Hospital ID tags or bracelets? If yes specify stated name and location: Body length (cm): Body weight (kgs):

12/28/2013 9:13:00 AM OMI Yes Visual Right wrist Decedent name Right wrist Decedent name Yes Left ankle Trauma-Alert, Hurdle C 128.00 27.00

Development: Development comments: Stature: Age: Anasarca: Edema localized: Dehydration: Skin comments:

Well-developed Thin Appears to be stated age No No No

Hyperpigmentation of the skin of the chest and back.


Scalp hair color: Scalp hair length: Eyes: Irides: Eyes corneae: Eyes sclerae: Eyes conjunctivae: Eyes petechiae: Palpebral petechiae: Bulbar petechiae: Facial petechiae: Oral mucosal petechiae:
External Examination

Brown Short Both eyes present Brown Translucent White Translucent No No No No No


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Case Number: Nose: Ears: Lips: Facial hair: Facial hair color: Maxillary dentition:

2013-06715

External Examination
Normally formed Normally formed Normally formed None Does not apply Natural Natural Adequate Unremarkable Yes Normal Yes Appropriate Unremarkable Unremarkable Normal Male None None Yes Yes Yes Yes Well-developed and symmetrical No No No No
Tattoo(s)

VARELA, OMAREE

Mandibular dentition: Condition of dentition: Neck: Trachea midline: Chest development: Chest symmetrical: Chest diameter: Abdomen: Back: Spine: External genitalia: Breast development: Breast masses: Right hand digits complete: Left hand digits complete: Right foot digits complete: Left foot digits complete: Extremities: Muscle group atrophy: Senile purpura: Pitting edema: Muscle other: Tattoos present:

No

Cosmetic Piercing(s) Cosmetic piercing present: Scar(s) present: Scar face: Scar right lateral neck:

No
Scar(s)

Yes Yes Yes

Reporting Tracking Reported by:


External Examination

Odey Ukpo MD Page 2


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Case Number: Verified by:

2013-06715

External Examination
Sam Andrews MD on 3/4/2014 4:08:13 PM Sam Andrews MD on 3/7/2014 4:50:48 PM

VARELA, OMAREE

Reviewed and approved by:

External Examination

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Case Number:

2013-06715

Medical Intervention
Medical Investigator Trainee Odey Ukpo MD

VARELA, OMAREE

Medical Investigator Sam Andrews MD Evidence of medical intervention:

Yes
Indwelling Tubes

If nasogastric tube present, specify course and position: Nasogastric tube: Nasogastric tube comment: If endotracheal tube present, specify course and position: Tracheostomy site/tube: Mediastinal tube(s): Chest tube(s): If Foley catheter present, specify course and position: Medical intervention other:

Yes Passes through the nose and nasopharynx, down the esophagus and terminates in the stomach No No No No No

Combitube within the esophagus. Recent needle puncture within the right antecubital fossa. Acute needle puncture of the left antecubital fossa. Pulse oximeter on the right hand.
ECG Monitoring Pads ECG Monitoring Pads Present?: ECG Chest Pads: ECG abdomen pads: ECG shoulders pads: ECG shins pads: Other pads comments: Defibrillator Pads Defibrillator pads present?:

Yes Yes Yes Yes Yes

No

Vascular Catheter(s): Vascular catheter(s): Left femoral vein:

Yes Yes
Recent Surgical Intervention

Evidence of recent surgical intervention:

No

Report Tracking Reported by:


Medical Intervention

Odey Ukpo MD Page 1


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Case Number: Verified by:

2013-06715

Medical Intervention
Sam Andrews MD on 3/4/2014 4:25:11 PM Sam Andrews MD on 3/7/2014 4:50:48 PM

VARELA, OMAREE

Reviewed and approved by:

Medical Intervention

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Case Number:

2013-06715

Postmortem Changes
Medical Investigator Trainee Odey Ukpo MD

VARELA, OMAREE

Medical Investigator Sam Andrews MD

External exam date: Body temperature: Rigor mortis: Livor mortis - color: Livor mortis - fixation (if applicable): Livor mortis - position (if applicable): State of preservation:

12/28/2013 9:16:00 AM Cool subsequent to refrigeration Partially fixed Purple Fully Fixed Posterior No decomposition

Report Tracking Reported by: Verified by: Reviewed and approved by: Odey Ukpo MD Sam Andrews MD on 12/28/2013 3:18:22 PM Sam Andrews MD on 3/7/2014 4:50:48 PM

Postmortem Changes

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Case Number:

2013-06715

Evidence of Injury
Medical lnvestigator Trainee Odey Ukpo MD

VARELA, OMAREE

Medical Investigator Sam Andrews MD

Are there any injuries:

Yes
Evidence of Injury:

Autopsy date:

12/28/2013 8:30:00 AM

Evidence of Injury

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Case Number: # Injury

2013-06715
Location

Evidence of Injury
Injury Description

VARELA, OMAREE

1 Blunt injury

Head

On the superior philtrum is a 0.5 x 0.5 cm red abrasion. On the lateral left supraorbital ridge is a 0.5 x 0.5 cm red/orange, dry abrasion. On the left parietal scalp is a 1.5 x 0.5 cm red laceration with granulation tissue at the base. On the anterior tongue is a 0.8 x 0.4 cm blue contusion.

2 Blunt injury

Chest

On the midline superior chest are three distinct, 0.5 x 0.5 cm, roughly square, orange, waxy abrasions. On the lateral upper left chest in a 4 x 3.5 cm area, are three distinct, circular, red contusions. There is hemorrhage within the lateral right 10th and 11th intercostal spaces. There is hemorrhage within the posterior right 11th intercostal space.

3 Blunt injury

Abdomen

There is 500 ml of liquid blood within the abdominal cavity. There is hemorrhage within the peripancreatic and left perirenal fat. There are irregular hemorrhages of the superior and inferior diaphragmatic surfaces. There is hemorrhage of the right internal oblique muscle. On the serosal surfaces of the small and large bowel are multiple patchy small contusions.

4 Blunt injury 5 Blunt injury

Back Extremity

On the midline lower back is a 2 x 2 cm blue contusion with associated subcutaneous hemorrhage. On the posterior distal right forearm is a 3 cm circular blue contusion. On the lateral distal left forearm are 2 cm and 1 cm circular purple contusions. On the posterior mid left forearm is a purple contusion. On the left knee is a 2 x 1 cm oval blue contusion. On the mid right shin is a 3 x 1.5 cm oval blue contusion.
Report Tracking

Reported by: Verified by: Reviewed and approved by:

Odey Ukpo MD Sam Andrews MD on 3/7/2014 4:49:43 PM Sam Andrews MD on 3/7/2014 4:50:48 PM

Evidence of Injury

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Case Number:

2013-06715

Internal Examination
Medical lnvestigator Trainee Odey Ukpo MD

VARELA, OMAREE

Medical Investigator Sam Andrews MD

Date of Autopsy: Date of Internal Exam:

12/28/2013 8:30:00 AM 12/28/2013 10:01:00 AM


BODY CAVITIES

Chest cavities examined: See evidence of injury section Organs in normal anatomic position Other organ position comments Diaphragm: Serosal surfaces: Body cavity adhesions present: Fluid accumulation present: Fluid accumulation right chest cavity: Fluid accumulation left chest cavity Fluid accumulation pericardial sac: Fluid accumulation abdominal cavity: Fluid accumulation pelvis: Fluid accumulation comments:

Yes Yes Yes

Other - see comments Smooth and glistening No Yes No No No No No

See Evidence of Injury


Body cavity other comments:

See Evidence of Injury


HEAD Brain examined: See separate forensic neuropathology consultation report See evidence of injury section: See evidence of medical Intervention section: See postmortem changes section: Brain fresh (g): Brain fixed (g): Facial skeleton: Calvarium: Skull base: Skull comments: Spinal Cord Spinal cord examined:
Internal Examination

Yes Yes No No No 1190 No palpable fractures No fractures No fractures

No
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No

Internal Examination
Middle Ears

VARELA, OMAREE

Middle ears examined: Neck examined: See Evidence of Injury section: See Evidence of Medical Intervention section See Postmortem Changes section: Subcutaneous soft tissues: Strap muscles: Jugular veins: Carotid arteries: Tongue: Epiglottis: Hyoid bone: Larynx: Palatine tonsils: Heart examined: See separate Cardiovascular Pathology report: See Evidence of Injury section: See Evidence of Medical Intervention section: See Postmortem Changes section: Right coronary ostium position: Left coronary ostium position: Supply of the posterior myocardium: Heart fresh (g): Heart fixed (g):

Neck

Yes No No No Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable
CARDIOVASCULAR SYSTEM

Yes No No No No
Heart

Normal Normal Right coronary artery 135


Coronary artery stenosis by atherosclerosis (in percent):

Right coronary ostium: Proximal third right coronary artery: Middle third right coronary artery: Distal third right coronary artery: Left coronary ostium: Left main coronary artery: Proximal third left anterior descending coronary artery: Middle third left anterior descending coronary artery: Distal third left anterior descending coronary artery:
Internal Examination

0 0 0 0 0 0 0 0 0
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0 0 0

Internal Examination

VARELA, OMAREE

Proximal third left circumflex coronary artery: Middle third left circumflex coronary artery: Distal third left circumflex coronary artery: Cardiac chambers: Tricuspid valve: Pulmonic valve: Mitral valve: Aortic valve: Right ventricular myocardium: Left ventricular myocardium: Atrial septum: Ventricular septum:

Cardiac Chambers and Valves:

Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable No fibrosis, erythema, pathologic infiltration of adipose tissue or areas of accentuated softening or induration No fibrosis, erythema, or areas of accentuated softening or induration Unremarkable Unremarkable
Aorta

Aorta examined: Orifices of the major vascular branches: Coarctation: Vascular dissection: Aneurysm formation: Complex atherosclerosis: Other aortic pathology: Great vessels examined: Vena cava and major tributaries:

Yes Patent No No No No No
Vena Cava

Yes Patent
RESPIRATORY SYSTEM

Lungs examined: See separate Cardiovascular Pathology report: See Evidence of Injury section: See Evidence of Medical Intervention section: See Postmortem Changes section: Lung right (g): Lung left (g): Upper and lower airways: Pulmonary parenchyma color: Pulmonary parenchyma congestion and edema: Pulmonary trunk:
Internal Examination

Yes No No No No 130 125 Unobstructed, and the mucosal surfaces are smooth and yellow-tan Dark red-purple Slight amounts of blood and frothy fluid Free of saddle embolus
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Case Number:

2013-06715
None None

Internal Examination

VARELA, OMAREE

Pulmonary artery thrombi: Pulmonary artery atherosclerosis:

HEPATOBILIARY SYSTEM Liver examined: See Evidence of Injury section: See Evidence of Medical Intervention section: See Postmortem Changes section: Liver (g): Bile vol (mL): Gallstones autopsy: Gallstones autopsy desc: Hepatic parenchyma (color): Hepatic parenchyma (texture): Hepatic vasculature: Gallbladder: Gallstones: Intrahepatic biliary tree: Extrahepatic biliary tree: Alimentary tract examined: See Evidence of Injury section: See Evidence of Medical Intervention section: See Postmortem Changes section: Stomach contents vol (mL): Stomach contents description: Appendix found: Course: Mucosa: Mucosa: Pylorus:

Yes No No No 615 No Red-brown Unremarkable Unremarkable and free of thrombus Unremarkable None Unremarkable Unremarkable
GASTROINTESINAL SYSTEM

Yes Yes No No

Yes
Esophagus

Normal course without fistulae Gray-white, smooth and without lesions


Stomach

Usual rugal folds Patent and without muscular hypertrophy


Small Intestine

Luminal contents: Mucosa: Caliber and continuity: Luminal contents: Mucosa: Caliber and continuity:

Partially digested food Unremarkable Appropriate caliber without interruption of luminal continuity
Colon

Formed stool Unremarkable Appropriate caliber without interruption of luminal continuity


Pancreas

Internal Examination

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Case Number: Form:

2013-06715

Internal Examination
Normal tan, lobulated appearance
GENITOURINARY SYSTEM

VARELA, OMAREE

Genitourinary system examined: See Evidence of Injury section: See Evidence of Medical Intervention section: See Postmortem Changes section: Kidneys capsules: Cortical surfaces: Cortices: Calyces, pelves and ureters: Kidney right (g): Kidney left (g): Urine volume (mL): Urine description:

Yes Yes No No
Kidneys

Thin, semitransparent Smooth Normal thickness and well-delineated from the medullary pyramids Non-dilated and free of stones and masses 45 55 0
Urinary Bladder

Urinary bladder mucosa: Male: Location: Size: Consistency: Other testicle comments:

Gray-tan and smooth


Male

Yes
Testicles

Bilaterally intrascrotal Unremarkable Homogenous


Prostate Gland

Size: Consistency: Other prostate gland comments:

Unremarkable Homogenous

RETICULOENDOTHELIAL SYSTEM Reticuloendothelial system examined: See Evidence of Injury section: See Evidence of Medical Intervention section: See Postmortem Changes section: Spleen (g): Spleen parenchyma: Spleen capsule: Spleen white pulp:

Yes No No No
Spleen

50 Moderately firm Intact Prominent


Bone Marrow

Color:
Internal Examination

Red-brown, homogeous and ample


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Internal Examination
Lymph Nodes

VARELA, OMAREE

Regional adenopathy: Thymus (g): Parenchyma: Endocrine system examined: See Evidence of Injury section: See Evidence of Medical Intervention section: See Postmortem Changes section: Size: Position: Size: Parenchyma:

No adenopathy
Thymus

Absent (involution by adipose tissue)


ENDOCRINE SYSTEM

Yes No No No
Pituitary Gland

Normal
Thyroid Gland

Normal Normal Homogenous


Adrenal Glands

Adrenal right (g): Adrenal left (g): Size: Parenchyma: Musculoskeletal system examined: See Evidence of Injury section: See Evidence of Medical Intervention section: See Postmortem Changes section: Bony framework: Musculature: Subcutaneous soft tissues:

Normal Yellow cortices and gray medullae with with the expected corticomedullary ratio
MUSCULOSKELETAL SYSTEM

Yes Yes No No Unremarkable See Evidence of Injury See Evidence of Injury


ADDITIONAL COMMENTS

Report Tracking Reported by: Verified by: Reviewed and approved by: Odey Ukpo MD Sam Andrews MD on 3/7/2014 4:49:46 PM Sam Andrews MD on 3/7/2014 4:50:48 PM

Internal Examination

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Case Number:

2013-06715

Neuropathology Examination

VARELA, OMAREE

Medical Investigator Sam Andrews MD Summary:

Medical lnvestigator Trainee Odey Ukpo MD

BLUNT HEAD TRAUMA: 1. Scalp laceration at systemic autopsy 2. Cerebral edema without frank herniation

According to reports, Omaree Varela was at home fighting with a sibling when he fell off of a rocking horse. His mother later admitted to kicking him several times, and at one point he struck his head. A formal extended examination of the brain demonstrated mild cerebral edema only. There were no significant natural diseases, and no injuries.

Brain exam date: Brain: Dura: Brain Dissection Method: Brain fresh: Brain fresh: Brain fixed:

1/22/2014 4:00:00 PM Yes Yes Cerebrum - coronal 1190.00

Evidence of Injury General Description (External): Dura mater: Dural venous sinuses: Cortical briding vein: Leptomeninges: SuperficialCorticalVasculature: Gyral convolution patterns: Gyral convolutions: Uncal processes: Cerebellar ponsils: Basilar arterial vasculature: Cranial nerve roots: Cerebral cortex: Gray-white matter junctions: Internal Capsule: Ventricular system:
Neuropathology

Smooth and without massess Patent Smooth and translucent No thromboses or vascular malformations Within normal limits Slight widening and flattening Not grooved or herniated Not grooved or herniated Normal Normal
General Description (Internal):

Intact and without contusion Distinct No neoplasm, cyst, abscess or hemorrhage Appropriately configured and not compressed
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Case Number: Deep gray nuclei: Hippocampi:

2013-06715

Neuropathology Examination No neoplasm, cyst, abscess or hemorrhage No neoplasm, cyst, abscess or hemorrhage No neoplasm, cyst, abscess or hemorrhage No neoplasm, cyst, abscess or hemorrhage No neoplasm, cyst, abscess or hemorrhage No neoplasm, cyst, abscess or hemorrhage No neoplasm, cyst, abscess or hemorrhage Normally pigmented Normally pigmented
Other Tissues Examined

VARELA, OMAREE

Other comment(s) about the deep gray nuclei: Mammillary bodies: Superior cerebellar vermis: Cerebellar parenchyma: Brainstem structures: Proximal cervical spinal cord: Substantia nigra: Locus ceruleus:

Spinal cord: Eyes: Cervical ppine:

Not examined Not examined Not examined


Microscopic Description

No significant histopathologic abnormalities. *Unless otherwise indicated sections are stained only with hematoxylin and eosin (H&E).
Cassette Code Tissue Location Stain

B1 B2 B3 B4 B5 B6 B7 B8 B9

Frontal lobe Hippocampus Parietal lobe Anterior basal ganglia Posterior basal ganglia Cerebellum Medulla Spinal cord Dura mater
Report Tracking

Reported by: Verified by: Reviewed and approved by:

Deirdre Amaro MD Evan Matshes MD on 2/10/2014 2:26:44 PM Sam Andrews MD on 3/7/2014 4:50:48 PM

Neuropathology

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Case Number:

2013-06715

Microscopy
Medical lnvestigator Trainee Odey Ukpo MD

VARELA, OMAREE

Medical Investigator Sam Andrews MD

Microscopic description:

HEART (left ventricle, interventricular septum, apex) Sections of the heart show no significant histopathologic abnormality. LUNGS Sections of the right and left lungs show no significant histopathologic abnormality. KIDNEYS A section of the right shows focal interstitial chronic inflammation. A section of the left kidney shows no significant histopathologic abnormality. LIVER A section of the liver shows no significant histopathologic abnormality. LEFT PARIETAL SCALP Sections of the left parietal scalp show a laceration cleft through the scalp to galea filled with mixed cellular debris and fibrin, and a prominent fibroblastic and granulation-like response. SKIN OF THE CHEST Sections of the skin from the chest show epithelium with smeared nuclei, karyorrhectic debris, and focal acute inflammation that does not extend to the adnexa. One focus shows epidermal detachment with coagulative necrosis and blue discoloration of the dermal-epidermal junction. BLADDER A section of the bladder shows no significant histopathologic abnormality. TONGUE A section of the tongue shows denuded and reactive epithelium with near full thickness acute inflammation with focal hemorrhage. *Unless otherwise indicated sections are stained only with hematoxylin and eosin (H&E).
Block Tissue Location Description Stain

A1 A2 A3 A4 A5 A6 A7

Heart, right kidney Right lung, left kidney Liver, left lung Left scalp Chest abrasions at sternal notch Bladder Tongue

Microscopy:

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Odey Ukpo MD

Microscopy
Report Tracking

VARELA, OMAREE

Reported by: Verified by: Reviewed and approved by:

Sam Andrews MD on 3/7/2014 4:49:50 PM Sam Andrews MD on 3/7/2014 4:50:48 PM

Microscopy:

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Radiography
Medical lnvestigator Trainee Odey Ukpo MD

VARELA, OMAREE

Medical Investigator Sam Andrews MD

Date of examination: Study date: Accession number: Exam type: Technique: Comparison: Comments:

12/28/2013 8:30:00 AM 12/28/2013 12:00:00 AM 2013-6715 Skeletal survey Radiograph

Review of the postmortem skeletal survey shows no acute or subacute fractures.


Report Tracking Reported by: Verified by: Reviewed and approved by: Odey Ukpo MD Sam Andrews MD on 3/4/2014 2:37:49 PM Sam Andrews MD on 3/7/2014 4:50:48 PM

Radiography

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Case Number: Decedent Name: Case Number:

2013-06715

Peer Review Report


VARELA, OMAREE 2013-06715 12/28/2013 8:30:00 AM Sam Andrews MD Odey Ukpo MD Evan Matshes MD
Items Reviewed

VARELA, OMAREE

Date of Examination: Pathologist: Fellow/Resident: Reviewer:

Death investigation report: Photographs: Microscopic slides: Toxicology report: Other Items (specify): Other Items Comments:

Yes Yes Yes Yes Yes

Radiographs (hands not radiographed) Full body computed tomography (PMCT) scan
Technical Audit Is the report independently reviewable?: Are the descriptions of clothing and identifying marks and scars appropriate for the complexity of the case?: Is the external description (without injuries) appropriately case specific?: Are the descriptions of injury, if present, appropriate for the complexity of the case, and consistent with diagrams and photographs?: Are the descriptions of injury, if present, organized in a logical and understandable sequence?: Are the descriptions of natural disease, if present, appropriate for the complexity of the case?: Is the text clear and understandable without significant typographical and/or grammatical errors?: Is the opinion logical and complete?: Is the opinion readily understandable by the nonmedical reader?: Are all significant issues addressed in the opinion?: Was appropriate ancillary testing performed?: Are the opinions reasonable?: Is the cause of death reasonable?: Is the manner of death reasonable?: Report completed in a timely fashion?: Comments: Report Tracking Reported by: Verified by:
Peer Review Report

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Select Option Evan Matshes MD on 3/7/2014 4:40:44 PM Page 1


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Case Number:

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Peer Review Report


Sam Andrews MD on 3/7/2014 4:50:48 PM

VARELA, OMAREE

Reviewed and approved by:

Peer Review Report

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Case Number:

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Procedural Notes

VARELA, OMAREE

Case Number: Decedent Name: Pathologist: Fellow/Resident: Date of Examination:

2013-06715 VARELA, OMAREE Sam Andrews MD Odey Ukpo MD 12/28/2013 8:30:00 AM


Morphology technican(s) present Yellow Sheet Autopsy Attendees Identification Evidence Evidence Radiology Retention Toxicology Toxicology Toxicology LabOther Morphology Technician Myranda McGowan Myranda McGowan Myranda McGowan Myranda McGowan Myranda McGowan Myranda McGowan Myranda McGowan Myranda McGowan Myranda McGowan Myranda McGowan Myranda McGowan

Morphology technican supervisor(s) present Yellow Sheet Toxicology LabOther Attendees Identification Autopsy Evidence Radiology Retention Morphology Technician Lead Erika Cavalier Erika Cavalier Monica Mondragon Monica Mondragon Stephen Adams Monica Mondragon Monica Mondragon Monica Mondragon

Procedural Notes Report

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Procedural Notes
Autopsy attendees Other morphology technicians present:

VARELA, OMAREE

Monica Mondragon

Law enforcement officers present:

Detective Michelle English with APD


Specimens obtained for toxicology testing Use antemortem specimens for testing: Femoral blood collected: Heart blood collected: Blood other collected: Preserved vitreous collected: Un-preserved vitreous collected: Urine collected: Bile collected: Gastric contents collected: Kidney tissue collected: Liver tissue collected: Brain tissue collected: Muscle tissue collected: Other tissue collected:

No Yes Yes No Yes Yes No No No No No No No No

Procedural Notes Report

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Procedural Notes
Specimens obtained for laboratory testing

VARELA, OMAREE

HIV serology: HIV spin and store: HCV/HBV serology : Influenza serology: Other serology: Freezer protocol: DNA card: Metabolic screen: Cytogenetics: Med-X protocol: Urine dipstick: Blood cultures (bacterial): Lung cultures (bacterial): CSF culture (bacterial): Spleen culture (bacterial): Stool culture (bacterial): Other bacterial culture (specify): Mycobacterial culture (lung): Mycobacterial culture (other): Viral Cultures:

No Yes No No No No Yes Yes No No No No No No No No No No No


Approach to autopsy dissection

Rokitansky evisceration: Virchow evisceration: Modified evisceration:

No Yes No

Procedural Notes Report

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Case Number:

2013-06715

Procedural Notes
Special autopsy techniques

VARELA, OMAREE

HIV serology: Pericranial membrane removal: Neck anterior dissection: Neck posterior dissection: Facial dissection: Vertebral artery dissection (in situ): Cervical spine removal: Layered anterior trunk dissection: Anterolateral rib arc dissection: Back dissection: Posterior rib arc dissection: Extremity soft tissue dissection: Eye enucleation: Inner middle ear evaluation: Maxilla or mandible resection: Spinal cord removal (anterior): Spinal cord removal (posterior): Other dissection(s):

No No Yes No No No No Yes No Yes No No No No No No No

Tissues retention Stock jar with standard tissue retention: Rib segment: Pituitary gland: Breast tissue (women only): Brain retention: Spinal cord retention: Cervical spine retention: Heart retention: Heart-lung block retention: Rib cage retention: Long bone retention: Other retention,specify: Disposition of tissues retained for extended examination Specimen outcome:

Yes Yes Yes No Yes No No No No No No

Fixation with standard disposal/cremation when examination complete

Procedural Notes Report

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Case Number:

2013-06715

Procedural Notes
Number of scene photos produced by the OMI

VARELA, OMAREE

Scene Photos:

168
Number of autopsy photos produced by the OMI

Autopsy Photos:

98
Evidence collected

FBI blood tube: Blood spot card: APD blood card: Thumbprint: Fingerprints: Palmprints: Print hold: Oral swab: Vaginal swab: Anal swab: Other swab: Fingernails: Scalp hair: Pubic hair: Pubic hair combing: Projectile(s): Retain clothing: Retain valuables: Retain trace evidence: Retain body bag: Retain hand bags: Ligature: Other evidence retained:

No No No Yes No No No No No No Yes No No No No No Yes Yes No No No No


Personal effects

Property Type Swabs Swabs Valuables

Property Description Other Other Other Clothing

Property Detail Swab- bite mark wet Swab- bite mark dry eye ointment

Property Type Clothing Clothing

Property Description Underpants Shorts

Procedural Notes Report

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