Www.forensic.gov.uk © Forensic Science Service Ltd. 2009. All rights reserved. The Forensic Science...

www.forensic.gov.uk

© Forensic Science Service Ltd. 2009. All rights reserved.The Forensic Science Service® is a trading name of Forensic Science Service LtdForensic Science Service Ltd. is a UK Government owned company

INVESTIGATION OF CHILD POISONINGWhat Can Forensic Toxicology Offer?

Michael Scott-HamSenior Forensic ScientistForensic Science Service,

London Laboratory

www.forensic.gov.uk

2© Forensic Science Service Ltd. 2009. All rights reserved.

OUTLINE OF TALK

Samples required

Drugs analysed

Detection times

Analysis

Interpretation

Case examples

3© Forensic Science Service Ltd. 2009. All rights reserved. 3© Forensic Science Service Ltd. 2009. All rights reserved.

SPECIMENS REQUIRED FROM LIVING SUBJECTS

Urine (10 to 20 millilitres normally required) Blood (5 to 10 millilitres normally required)Hair (If long-term abuse is suspected)

Samples must be taken as soon as practically possible.(A doctor is not necessarily required for urine samples.)


REQUIREMENTS FOR TOX SAMPLES

Blood and urine need to be preserved and well sealed.Glass universal bottles/Medex® Vials/RTA Vials/Vacutainers preferable.Preservatives - fluoride, oxalateSamples should be refrigerated or frozen (frozen if volatiles are suspected).Hair Sampling – follow Hair Testing Protocol.

Items suitably sealed and labeled for continuity.Date and time the sample was taken – important for result interpretation.Continuity statement likely to be required later by PoliceEach sample given a unique exhibit number.Use of Forensic Evidence Bags (e.g. SceneSafe®)


INFORMATION REQUIRED BY TOX

Paperwork documenting case circumstances and continuity of items.

Information regarding type and duration of patient symptoms.

Immediate family prescription/drug use information.

Suspected drugs/Alcohol?

Timescale of incident – one off event/suspected long-term abuse


LABORATORY PROCEDURE

AlcoholCommon Drugs of Abuse

Amphetamine, methylenedioxymethylamphetamine (MDMA) and other associated ‘Ecstasy’ type drugs.Compounds expected following the use of cocaine.Methadone, ketamine, diazepam and temazepam.Opiate drugs (e.g. heroin, morphine, codeine and dihydrocodeine).Compounds expected following the use of cannabis or cannabis resin.

Medicinal Drugs – tests carried out for basic, acidic and neutral drugs.

includes various antihistamine, antipsychotic and antidepressant drugs, SSRI’s, common analgesics. As much information as possible required to assist with targeted testing.


LABORATORY PROCEDURE CONT.

Sedative DrugsGamma-hydroxybutyrate (GHB) and gammabutyrolactone (GBL).Benzodiazepine drugs including flunitrazepam, diazepam, temazepam, lorazepam, lormetazepam, flurazepam, midazolam, alprazolam and clonazepam. Zopiclone, zolpidem and zaleplon.Barbiturates. Chlorinated compounds - chloral hydrate (‘Welldorm®’).


DETECTION TIMES

DETECTION TIMES FOR DRUGS ARE LONGER IN URINE THAN IN BLOOD.e.g. for drugs of abuse

BloodGenerally 12 to 24 hours.

UrineGenerally 24 to 72 hours.

Detection times for prescription medication vary.


DETECTION LIMITS

Alcohol – eliminated from an adult body at a constant rate of between 10 and 25mg% per hour. N.B Elimination rate in children may be faster.

Common drugs of abuseBlood Urine

Amphetamine 12 hours 1-2 days‘Ecstasy’ 18 hours 2-3 daysCocaine 18 hours 2-3 daysHeroin/morphine 12 hours 1-2 daysKetamine 6 - 12 hours 12 - 24 hoursCannabis/cannabis resin depends on pattern of use


DETECTION LIMITS CONT.

Prescribed/abused drugs Blood UrineDiazepam, temazepam 2 days 4 daysMethadone 1 day 2-3 days

Potential sedatives Blood UrineFlunitrazepam 12-24 hrs 3 daysGHB 6 hours 12 hoursBarbiturates 1+ day 2+ days

Detection time for hair samples……?


ALCOHOL

Alcohol tested using headspace gas chromatography.

Concentration of alcohol measured in milligrams per 100 millilitres (mg%)

Measured level represents situation at the time the sample was taken.

Back calculation carried out to time of incident (if required)Allows for alcohol elimination between the incident and sampling time.General interpretation of effects given.

Forward calculation to estimate volume of alcohol consumed/administeredalso possible.

Child’s height and weight and drinking pattern (type of alcohol) required to carry out this calculation.


DRUGS OF ABUSE

Initial screening tests –

Enzyme Immunoassay Analysis for common drugs of abuse.DART MS– useful for initial screening of non-biological liquids.Quick initial screens – preliminary results can be available in 24 to 48 hours.

Confirmatory tests including sedative and medicinal drug screening carried out using the following techniques -

GC-MSHPLCLC-MS

Quantification of drug concentration only carried out on blood samplesUseful to obtain blood samples in addition to urine if possible.


HAIR/POISONS????

Poison ScreeningCan test for other compounds if circumstances suggest e.g. pesticides, metals, household chemicals?

Hair testingCan be carried out segmentally to identify pattern of ingestion over weeks/monthsCan test for variety of drugs but generally requires bespoke methods –can be expensive

Reports via a full CJ Act Witness Statement including detailed interpretation of the results obtained.


QUESTIONS CONSIDERED BY THE TOXICOLOGIST

Has the child been administered a drug and/or alcohol?

Has the drug/alcohol been administered with the intent to cause effect?

Could it have been accidental (e.g. herbal cannabis left within reach of a child?)Inadvertent transfer through breast milkPassive inhalationNeonatal abstinence syndrome

What effects would the drug/alcohol have on the child?Symptoms – dosage dependentCause of death?

Has the child been administered a drug/alcohol over an extended time period?

Hair analysis


CASE EXAMPLES

Methadone poisoning

Opiate poisoning

Shannon Mathews


CIRCUMSTANCES

Ambulance called 5.53amResuscitation attemptedChild (2 y.o.) pronounced dead 6.47am

Ambulance had attended 7pm previous eveningChild feverish but otherwise OK; advised to give ‘Calpol® ’ every 4 hours

Found at scene:Bottle of ‘Calpol® ’‘Chesty Cough Linctus’Empty methadone bottle (prescribed to lodger)Other drug paraphernalia

Mother still breast-feeding child


POST-MORTEM EXAMINATION

Carried out 3 days after death

Samples takenFemoral blood (small)

Heart blood

Vitreous humour

Stomach content


ANALYSIS

Heart blood screened for alcohol, common drugs of abuse and paracetamol:

No alcohol detectedHigh positive methadone EIAParacetamol <5µg/mlNegative other drugs

Femoral blood submitted for methadone quantification Insufficient blood for full quantificationMethadone was confirmed as being present

Contents of bottles confirmed as being as labelled (no methadone present)


FURTHER ANALYSIS

What now?

Possibilities:Quantify heart blood, vitreous humour

Other samples ?


FURTHER ENQUIRIES

No other samples had been taken at p-m

Requested samples of muscle tissue and liverbody thawed out and 4 muscle samples taken from legs as well as a sample of liver


FURTHER ANALYSIS

Methadone levels:-Vitreous humour 0.15µg/ml

Heart blood 0.29µg/ml

Right thigh muscle 0.72µg/g

Right calf muscle 0.71µg/g

Left thigh muscle 0.67µg/g

Left calf muscle 0.63µg/g

Liver 2.5µg/g


FURTHER ANALYSIS

Right thigh muscle – pholcodine detected (therapeutic level)

Stomach content – <0.02mg methadone in total


INTERPRETATION

No femoral blood methadone level – possible problems with post-mortem interpretation

Conversion of heart blood to femoral blood – wide range of ratios

in the few published papers

Little published data on muscle or liver levels

No published data on vitreous humour levels -one FSS London case for comparison


INTERPRETATION

Femoral blood level (as calculated by conversion from heart blood ratio range) within the published fatal range

Heart blood level typically 2-3 times higher than lowest published fatal levels

Liver level within the published fatal range

Muscle levels all above the published fatal levels

Vitreous humour level consistent with previous fatal case

Stomach content –no suggestion of recent methadone ingestion


INTERPRETATION

Source of methadone?

Defence suggested ingestion of breast milk –feasible?

Methadone level in breast milk typically 0.1-0.2µg/ml; highest reported 0.57µg/ml

Ingestion of one litre would deliver 0.1- 0.2mg of drug (0.57mg highest)

Drug metabolism also occurring in interim (would not ingest one litre in one sitting!)

Cannot possibly account for measured levels; likely to need minimum of 10mg of methadone to produce measured levels


OTHER EVIDENCE

Hair from childShowed regular ingestion of:

MethadoneCocaineHeroin

Mother also a regular drug user (from hair analysis)HeroinCocaineMethadone (although not prescribed)


TRIAL (MAY 2006)

Court No. 2 Old BaileyMSH gave evidence over whole of morning session (experience questioned!)ARWF gave evidence over whole of afternoon sessionJury could not agree on a verdict and therefore discharged

Re-trial – June 2006Jury again failed to reach a verdictJudge recorded formal ‘not guilty’ verdictDefendant had earlier pleaded guilty to a charge of neglect


1 month old baby –died end February.

Victim placed into a rucksack by parents who travelled several 100 miles to visit baby’s grandparents.

Grandparents alerted the police after being shown the body.

Post-mortem carried out 3 days later - no obvious cause of death.

Samples submitted by police 2 months after death “for completeness”

Initial samples taken included – BloodUrineStomach Contents

CIRCUMSTANCES OF CASE


Parents’ house searched and the following items recovered –

Karvol® Decongestant capsules x 17 + box (3 used)20 mg Seroxat® Tablet blister pack (2 tablets remaining)Bottle of Calpol® (approx 2.5mls remaining).Empty Distalgesic® blister pack (Co-Proxamol)Empty bottle marked Clonazepam 24 x 0.5mg tablets.Empty container marked Nytol® Herbal tablets x 28 Empty bottle marked paracetamol 500mg x20

Various feeding bottles, milk powder, gripe water and several items of clothing also seized.


Blood - PreservedAlcohol 15 milligrams per 100 millilitres of bloodStrong positive EIA screening test for opiate drugs and specific

morphine!!

Urine - UnpreservedAlcohol 42 milligrams per 100 millilitres of urineLow level of micro organisms.Strong positive EIA screening test results for opiate drugs and specific

morphine.

ANALYTICAL FINDINGS


ANALYTICAL FINDINGS

Blood - Preserved

Free Morphine 2.1 micrograms per millilitreTotal Morphine 3.7 micrograms per millilitre

(measured as morphine)

Paracetamol ~ 140 micrograms per millilitreMonoacetylmorphine and codeine also detectedInsufficient blood for further analysis


Stomach Contents

Morphine ~ 20 micrograms per millilitre.

Total weight of stomach contents approximately 2 grams

Total morphine in stomach = approximately 40 micrograms.

ANALYTICAL FINDINGS


ANALYTICAL FINDINGS

Muscle sample taken at a later stage (5th June) at my request.

Muscle (Taken From Thigh)

Free morphine ~2.5 micrograms per gram of tissue.

Total morphine ~3.1 micrograms per gram of tissue.

Paracetamol ~131 micrograms per gram.

Propoxyphene ~3.1 micrograms per gram.


Results indicate possibility that the victim had been administered alcohol prior to his death.

Unable to estimate blood alcohol level at the time of death.Children can eliminate alcohol at a faster rate than adults (e.g. Gibson et al.

1985, Leung 1986, Vogel et al. 1995).Possibility of micro-organism activity prior to post-mortem (at least a 3 day

period between death and post-mortem).Samples submitted 2 months later.Urine sample not preserved – micro organisms present.Unknown how samples were stored.

ALCOHOL


Detection of monoacetylmorphine proves heroin ingestion.

Concentration of morphine very high and within the toxic range .

Ratio of ‘free’ to ‘total’ morphine consistent with ingestion of heroin within a few hours of death – although post-mortem changes must be considered inc.

Possibility of morphine glucuronide breakdown to ‘free’ morphine.Post-mortem redistribution - blood sample taken from the heart.Diffusion back into the stomach.

MORPHINE/HEROIN


Thigh muscle sample taken at a later date to assist with interpretation.

Muscle results obtained in agreement with the blood.

Low level of morphine also detected in the stomach contents.

Too low to substantiate method of administration – possible diffusion?

MORPHINE/HEROIN


Paracetamol arisen from Calpol® and/or Distalgesic® tablet administration?

Recommended dose of Calpol® to babies under 3 months is 2.5 ml of a 120mg/5ml solution (60 mg paracetamol).

Equivalent to approximately 15 mg paracetamol per kg body weight (15mg/kg).

Suggested maximum therapeutic paracetamol concentration - approximately 25 micrograms per millilitre following dosage at approximately 30 mg/kg (double recommended dose).

Measured concentrations ~140 micrograms per millilitre in blood.~131 micrograms per gram in muscle.

The paracetamol level detected is unlikely to have been life-threatening on it’s own, however is higher than recommended.

PARACETAMOL AND DEXTROPROPOXYPHENE


Propoxyphene was detected in the muscle sample.

Propoxyphene concentrations in muscle significantly (2-4 times) greater than in blood (e.g. Langford et al. 1998, Barnhart et al. 2001, Christensen at al. 1985).

Therefore measured level of 3.1 micrograms per gram of muscle ≡ 0.8 to 1.5 micrograms per millilitre of blood.

Blood concentrations exceeding 1 microgram per millilitre represent serious toxicity.

Combined with paracetamol results suggest possible administration of 1 to 2 Distalgesic® tablets.

Paracetamol and propoxyphene also detected in stomach contents (v. low)


OTHER RESULTS

Glass feeding bottle contained approximately 2.5 ml pale pink liquid.

Paracetamol (~50mg), propoxyphene (~3.4mg) and a trace level of morphine detected in the liquid.Paracetamol and propoxyphene also detected on the outside of the teat attached. Uncooked starch grains also seen under polarised microscope.

Alcohol detected in some of the liquids analysed – produced whilst in storage?

Evidence that other items of clothing seized may have been in contact with illicit heroin, cocaine, propoxyphene and paracetamol.


Deceased had ingested a potentially life-threatening amount of heroin. Unable to say how the drug was given or the amount ingested.

Had also ingested a potentially toxic dose of dextropropoxyphene (and paracetamol).

Significant interactions can occur between heroin and dextropropoxyphene to increase overall toxic effects inc. respiratory depression.

Other results indicate that the deceased may also have been administered alcohol.

Deceased had not been administered paroxetine, clonazepam or any of the other common drugs of abuse tested for prior to his death.

CONCLUSIONS


THE TRIAL

Prior to the trial there had been two defence examinations (each parent represented separately)

Evidence-in-Chief

Cross –examination

www.forensic.gov.uk

© Forensic Science Service Ltd. 2009. All rights reserved.The Forensic Science Service® is a trading name of Forensic Science Service LtdForensic Science Service Ltd. is a UK Government owned company

OPERATION PARISThe Shannon Matthews Case

Toxicologist: Dr Craig Chatterton

www.forensic.gov.uk


OPERATION PARIS : Case Circumstances

West Yorkshire Police received a call from Karen MATTHEWS shortly before 7pm on the 19th February 2008 stating that her 9 year old daughter, Shannon, had not returned home from school. WYP initiate an intense search and open a major investigation

Significant media interest throughout the search including TV documentaries involving Shannon’s family

The media link this case to the (unsolved) abduction/disappearance of Madelaine McCann in Portugal the previous summer

On the 14th March 2008, twenty-four days after going missing, Shannon is located at the home address of Michael DONOVAN

Urine sample collected for forensic investigation – suspicion that Shannon may have been drugged in order to facilitate the abduction and also whilst in captivity


OPERATION PARIS : Initial information / intelligence

½ a packet of Traveleeze® (meclozine) medication found at DONOVAN’s address together with a till receipt dated 13.03.08. During interview, Shannon claims to have been given a white tablet

DONOVAN’s medical records / history investigated. Drugs which form part of his recent prescription include:

Amitriptyline anti-depressant

Clonazepam anticonvulsant

Dihydrocodeine opioid analgesic

Temazepam hypnotic

Tramadol non-opioid analgesic


OPERATION PARIS : Results and interpretation

Drugs detected in the urine sample:

Temazepam and its metabolite Oxazepam

Meclozine and associated metabolites

Unable, from analysis of urine sample, to determine specifically when these drugs were ingested; both drugs can cause drowsiness

A single dose of temazepam is typically detectable in urine for 2 to 3 days

Drugs have been ingested shortly before sample collection on the 14th March 2008, i.e., whilst Shannon in captivity rather than before she went missing


OPERATION PARIS : Further investigation - hair

Initial analysis on item CAF120 – obtained 16.04.08

Drug detected 0 to 3cm 3 to 6cm 6 to 9cm 9 to 12cm

Amitriptyline 54 141 317 1099

Nortriptyline 35 110 189 687

Temazepam 2 6 6 8

Tramadol 110 230 450 720

Dihydrocodeine 23 21 49 67



Subsequent analysis on item MEAC1 – obtained 19.03.08

Drug detected 0 to 3cm 3 to 6cm 6 to 9cm 9 to 12cm

Amitriptyline 124 528 1097 1484

Nortriptyline 72 284 513 609

Temazepam 4 9 23 37

Tramadol 500 1300 2500 5000

Dihydrocodeine 100 300 900 1200



Subsequent analysis on item AJG10 – obtained 23.05.08

Drug detected 0 to 3cm 3 to 6cm 6 to 9cm 9 to 12cm 12 to 15cm 15 to 18cm

Amitriptyline 5 19 61 121 156 182

Nortriptyline 2 13 46 83 111 114

Temazepam 2 4 7 9 13 12

Tramadol 30 90 220 380 540 860

Dihydrocodeine 10 20 40 90 120 140


OPERATION PARIS : Initial interpretation

Findings demonstrate the ingestion of each drug by Shannon Matthews

Pattern / distribution indicates ingestion on more than 1 occasion

Presence of drug in each segment indicates extended period of time

Ingestion occurred before February 2008, i.e., before disappearance

Could indicate ingestion over period of greater than 12 months

Growth rate varies between 0.7 and 2.2 cm / month

Average growth rate is 1cm per month


OPERATION PARIS : Interpretation issues

Can we be certain of orientation ?

When did the ingestion of drugs begin ?

Why is the concentration of drug highest at the distal end ?

Can a dosage be estimated from the concentration detected in hair ?

Is there anything special about the mixture of drugs ?

Can a more definitive pattern of ingestion be established / investigated ?

Can the rate of hair growth be established ?



Can we be certain of orientation ?

Yes – this was verified by microscopic analysis

When did the ingestion of drugs begin ?

Require growth rate and more analysis to determine

Why is the concentration of drug highest at the distal end ?

Not yet known – several possibilities

Can a dosage be estimated from the concentration detected in hair ?

No, not really



Is there anything special about the mixture of drugs ?

Similar effects, i.e., drowsiness

All part of DONOVAN’s prescription

Can a more definitive pattern of ingestion be established / investigated ?

Yes but this requires more analysis

Can the rate of hair growth be established ?

Yes, West Yorkshire Police to take this forward



Amitriptyline & Nortriptyline

0

50

100

150

200

250

300

350

0 to1

1 to2

2 to3

3 to4

4 to5

5 to6

6 to7

7 to8

8 to9

9 to10

10to11

11to12

12to13

13to14

14to15

15to16

16to17

17to18

18to19

19to20

end

Amitriptyline CAF120 pg/mg Amitriptyline AJG10 pg/mg

Nortriptyline CAF120 pg/mg Nortriptyline AJG10 pg/mg



Temazepam

0

5

10

15

20

25

30

35

0 to1

1 to2

2 to3

3 to4

4 to5

5 to6

6 to7

7 to8

8 to9

9 to10

10to11

11to12

12to13

13to14

14to15

15to16

16to17

17to18

18to19

19to20

end

Temazepam CAF120 pg/mg Temazepam AJG10 pg/mg



Tramadol

0

500

1000

1500

2000

2500

0 to1

1 to2

2 to3

3 to4

4 to5

5 to6

6 to7

7 to8

8 to9

9 to10

10to11

11to12

12to13

13to14

14to15

15to16

16to17

17to18

18to19

19to20

end

Tramadol CAF120 pg/mg Tramadol AJG10 pg/mg


OPERATION PARIS : Final interpretation & conclusions

Shannon Matthews ingested drugs during her time period in captivity

In the day or so prior to her discovery on the 14th March 2008, Shannon Matthews had ingested the prescription-only hypnotic drug temazepam and the antihistamine / antiemetic drug meclozine

Hair analysis demonstrates that Shannon Matthews had ingested amitriptyline, temazepam, tramadol, dihydrocodeine and meclozine in the months leading up to her disappearance in February 2008

The findings demonstrate ingestion on more than one occasion; the distribution of the drugs in Shannon’s hair indicates that all of these drugs were ingested during the same time periods

Based on the established growth rate, the peak in drug concentration in the 10 to 11cm segment coincides with a time period between January and April 2007

Based on the established growth rate, the peak in drug concentration in the 16 to 17cm segment coincides with a time period between May and August 2006


OPERATION PARIS : Leeds Crown Court Nov 11 – Dec 2

On Tuesday 2nd December, after 6 hours of deliberations, a unanimous verdict was returned

Karen MATTHEWS and Michael DONOVAN were found guilty of all charges

Kidnap, False Imprisonment and Perverting the Course of Justice

Judge indicated that both persons should expect a lengthy custodial sentence


Acknowledgements

With thanks to:

Elizabeth Hird for preparing the presentation

Craig Chatterton (FSS Chorley) who reported the Shannon Matthews case

Contact details:

E-mail: Michael. [email protected]

Tel.: 020-7160-4254

Www.forensic.gov.uk © Forensic Science Service Ltd. 2009. All rights reserved. The Forensic Science...

Documents

Transcript of Www.forensic.gov.uk © Forensic Science Service Ltd. 2009. All rights reserved. The Forensic Science...