The Saga of Bill Carter, Part 3

Editor's Note: The following short series involves a case in which the author was involved. Read Part 1 here, and Part 2 here.

Part 3: Clues On a Night-Covered Road

The first time Bill and I spoke on the phone was a frozen cold Sunday night in mid-January, with the wind howling around my backyard. Bill’s voice cracked as he related and relived the details of the night that changed his life. He gave specific details of the dosages and times that Connor was medicated and spent a lot of time describing the fentanyl patch and his decision to have his son use it.

Whenever Bill mentioned Connor, his voice cracked and sounded as mournful as the wind outside my window. As I watched the moonlight shine on my own sleeping son from his darkened bedroom doorway, Bill broke down on the phone repeating “what a great kid” Connor was. Bill choked on his words, as if afraid of his own voice when he said, “I need someone to tell me if I killed my own kid.” His words were plaintive and damaged and haunting, and they stayed with me long after I hung up the phone.

Bill described the problems getting the autopsy results from the medical examiner and it seemed hard to believe. Lancaster County is about 60 miles and 100 years from my home in the Philadelphia suburbs, but what Dr. Carter described defied explanation. In fact the whole criminal complaint defied logic. I thought that only the State Medical Board had the authority to strip a doctor of his medical license.

I told Bill that it was very likely that I wouldn’t be able to give him the answers that he was looking for. Without the full autopsy I really couldn’t state what had killed Connor - that was the medical examiner’s job. All I could do was examine the reports that were provided and give him some context as to how they relate to other post-mortem serum levels of the same combination of drugs in similar circumstances of death as reported in the forensic literature.

I told Bill that I wouldn’t try to spin the results in any way and I refused his offer of payment for my services. If he paid me it would be difficult to tell him the truth.

The toxicology results arrived a few days later and I went to work.

Every time I’m asked to do this type of assignment I approach the job with a great deal of trepidation and anxiety. I hate this stuff. Forensic toxicology is quasi-science. There is always some missing piece of data or some aspect of the analysis that is a quantum leap of guesswork. There is almost never an opportunity to give a definitive answer about anything - just an educated guess that can be picked apart by anybody with the slightest hint of healthy skepticism.

The medical examiner had done a credible job of testing several different fluids for quantitative levels of oxycodone, fentanyl, and promethazine, and each one was well below what would be considered toxic or even therapeutic in most instances. It is important to compare apples to apples so when I looked at the combination of the different agents in published cases of similar deaths, I became confused. In all the cases of death caused by oxycodone plus another respiratory depressant drug (like in this case fentanyl) the levels of oxycodone were many times higher than the post-mortem results reported in Connor Carter’s blood. Similarly, when published cases of death caused by transdermal fentanyl are analyzed, again, in the context of multiple medication ingestion, the levels in Connor Carter’s blood were an order of magnitude lower than what I was able to identify in the published forensic literature.

Promethazine has been reported to amplify the respiratory depressant effects of opiates, but that is not quite accurate. Promethazine will prolong the length of time that opiates will depress the central nervous system, but it won’t make the depression any deeper; so you sleep longer but not more soundly. The post-mortem promethazine levels in Connor Carter’s blood were barely even measurable.

It was clear that the levels of oxycodone, fentanyl, and promethazine in Connor Carter’s post-mortem samples were not consistent with any previously published reports of death associated with any one of those agents or any combination of them.

As I came to this realization I stared out my window and the questions started coming faster than the snowflakes falling down and swirling around during the first big blizzard of the year. Why were the Carters told that the levels of the drugs in Connor’s blood were “sky high” when they were anything but? Why were the autopsy results withheld and contingent on the surrender of Dr. Carter’s medical license? Why would the district attorney come down so hard on Dr. Carter; a man that had just lost his son? Wasn’t there anything more pressing and important to the citizens and taxpayers of Lancaster than the circumstances of the death of Connor Carter?

The questions became even more troubling when the rest of the autopsy results were finally released.