Direct Exam:John Arnold

Dr. Uptegrove is the elected coroner for Warren County and also a deputy coroner and forensic pathologist in Montgomery County, which performs autopsies for about 20 counties. He was appointed coroner of Warren County in 2007 and elected to the position in 2008. He originally worked with the previous coroner, Dr. Warren Young in 2003 and then was hired as a deputy coroner in 2004.

He completed a fellowship program in forensic pathology in Charleston, SC and then moved to Ohio in 1999 to begin his job with Montgomery County. He performs about 230 to 275 autopsies a year and is also involved in training other forensic pathologists, law enforcement officers and investigators. He’s a guest lecturer at the Police Officers Training Academy and has testified in court approximately 10 times a year for the last 12 years.

Arnold asked about his policy in suspicious deaths and Uptegrove replied that these cases are referred to the coroner's office and by law, the only cases he's required to do autopsies on are cases involving children under 2 years old. However, all coroners don't have the same policies and he conducts an autopsy for all unknown deaths.

He considers the scene of the death and circumstances when determining if an autopsy should be done. Where the victim was found and under what circumstances is important.   After the autopsy is done, those findings, scene information and a person's history are considered when determining a cause of death. There are 3 points to consider when ruling on the cause of death; agent [what weapon was used], injury [what injury caused the death] and event [what was the scenario when the death occurred].   He is also required to give a reason for the manner of death and there are 5 choices; natural, accident, homicide, suicide and undetermined.

The night of Sarah's death, Uptegrove was called by chief examiner Doyle Burke who was on his way to Bethesda Arrow Springs to see an unresponsive 24-year-old female. Burke gave him a brief outline of the situation and said it didn't look as if the victim would live. When it appeared she had drowned, Uptegrove ordered an autopsy.

He performed the first autopsy on Sarah the morning after her death and prepared the autopsy report but he didn't prepare the toxicology report. It's sent to another county for analysis, but all reports become part of the file about Sarah's death. He had two assistants help him during the autopsy and Doyle Burke and Lt. Braley were also present but didn't take part. He said that investigators often attend autopsies and give him details about the crime scene to help him.

About 45 photos were taken and a photo of Sarah's face was put up on the screen after the endotracheal tube was removed. There were numbers and letters on the photo and Uptegrove explained that they are used for their record keeping. A photo of a side view of Sarah's face was shown, before the endotracheal tube was removed. The first thing he noticed was a large amount of blood-tinged white foam which had dried around her mouth, but was still coming out of the endotracheal tube. He called this pulmonary edema and said it was common in a drowning and a drug overdose, but because it was tinged with blood, that indicated it was a drowning.

Photos are taken first, then the body is examined. External injuries are not always visible at the time of the autopsy, because the injuries could be internal only. He did note some external injuries. The exam is always started at the head and he noticed Sarah had a faint bruise on the right side of her forehead near the hairline. He couldn't definitely say whether or not medical personnel caused it, but it wasn't in an area that routinely had EMT-type injuries.

A photo was placed on the screen of Sarah's eye with the inside of her eyelid exposed showing hemorrhages --small red dots inside the eyelid. He explained that she had petechial hemorrhaging in her eyes which could have been from drowning or CPR given to her. Arnold asked if the paramedic who rested his arm on the left side of Sarah's forehead during CPR, could have caused bruising, but Uptegrove said there was no bruising on the left side of the forehead.

A photo was shown of the left side of her neck showing a large bruise. Uptegrove said there were numerous attempts to insert an IV line into her artery and the bruising could have been from that, but there was no indication that this injury extended to the other side of her neck.

A photo showed a 3/4-inch abrasion near her armpit but Uptegrove didn't know if that was caused by resuscitation attempts. Another photo showed her upper lip with two lacerations on the left side and another on the right side. Some frothy fluid showed in her nostril. Sarah's chin and mouth were visible with a gloved finger pulling open her mouth, showing her teeth and the inside of her upper lip. The intubation tube was still in place. Uptegrove said if it was a difficult intubation, people can get lacerations inside the mouth or broken and chipped teeth but Sarah's teeth were intact. He said there were several possibilities that could have caused the lip lacerations, including intubations or blunt force injury from a fall. Those were all of the external injuries that he noticed.

A diagram of a person was put on the screen and Uptegrove used a red laser to draw a Y-shaped incision for the jury to visualize. It extended from the shoulders down the chest, and the points met in the area between the breasts. He said the skin is cut first, then underlying fat and muscle, then each side of the chest is pulled open to expose the interior of the body.

A diagram of the human neck was shown and Uptegrove explained that there was hemorrhaging in the top part of Sarah's sternum, near her shoulders but he didn't see any other hemorrhaging in the chest area which meant that Sarah was already deceased when first responders arrived. An autopsy photo was put on the screen showing bruising in the middle of Sarah's neck, in front. His opinion was that the hemorrhaging in her neck was either caused by compression force or a blunt force injury, not by CPR because CPR injuries are usually rib fractures or bruising around the heart area, and Sarah had no injuries like that.

A diagram placed on the overhead was a graphic of a person's head, neck and shoulders. The person's head is looking up and back. He pointed out the collar bone and pointed to where he noticed hemorrhaging inside the neck. Then a photo of this area with Sarah's throat and neck exposed was put on the screen and Arnold asked where hemorrhages were on Sarah's neck. Uptegrove pointed to his own neck at the Adam's apple.

He said the location of the hemorrhages, were inconsistent with where they would be found if they were a result of CPR. Neck hemorrhages are usually a result of injury while the person is still alive. In his opinion, they were from a blow to the neck, compression force or blunt-force trauma to that area and they happened before her death because it's more difficult for hemorrhaging or bruising to show up when there is no pulse. This would also be the reason why no bruising was found from the vigorous chest compressions. He went on to say that there were no injuries to her ribs because skeletal systems are different based on age, and bones are more pliable in young people than a 50-yr-old.  

After examining Sarah's external injuries, he went on to examine her internal organs by removing her chest plate to expose the chest cavity. He explained how he used a pair of clippers to remove the sternum and ribs. Arnold then handed him a large pair of clippers, which he held up, and explained they are like pruning shears. As the internal organs are removed one by one, they will be weighed and examined individually, looking for any sign of trauma or natural diseases.

First he examined the pulmonary artery to check for clots, which is often the cause of sudden death, but he didn't see any in Sarah. He then examined her heart by removing it from the chest cavity and didn't find any evidence of a murmur, cardiac event, defect or damage to her heart. He took thin samples of tissue to place on slides and examine under a microscope looking for things not visible to the naked eye.

Next, he examined the lungs and a photo was placed on the screen, showing Sarah's lungs. Using a red laser, he pointed out the frothy white fluid and said the lungs were heavy with water. Tissue samples were taken to look for other evidence and he found some bacterial colonies present, which could have come from the inhalation of water, but there was no infection.

The next organ removed was the liver. He did not see any laceration in the liver but there was a gouge mark on the liver, which frequently happens if the clippers nick the liver while cutting the rib cage. If the liver was lacerated or injured by CPR, there would be an enormous amount of blood in the abdominal cavity but there was no blood.

The pancreas and stomach were then removed and there was no sign of disease. Adrenal glands, just above the right and left kidneys were removed along with the kidneys, and they showed no sign of disease.

He then removed the uterus, ovaries, bladder and urinary tract. He knew first responders had noticed vaginal bleeding but he saw no bleeding, bruising, tearing or trauma in the rectal or vaginal area. There was 'no source' for the vaginal bleeding and nothing in his examination indicated bleeding had ever occurred.

Next he examined her head by opening it with an incision starting behind one ear and going over the head , ending behind the other ear. Arnold then placed another photo from the autopsy on the overhead screen and Uptegrove told the jury they were looking at Sarah's scalp, which had been pulled down over her face. On the underside of her scalp, he found contusions and bruising on the right side above her ear that was not seen during the external exam. He said some kind of blunt-force trauma made these injuries, because they're not consistent with CPR or any other medical efforts.

He then exposed her brain, did a visual exam first, and then removed it from the cranial opening. He didn't find any evidence of abnormalities, aneurysms, brain injuries or tumors. He then dissected the brain and took tissue samples to examine under his microscope, but didn't find any diseases.

The last portion of his exam would involve removing the neck organs and once that was done, he looked at the interior of the neck. There was evidence in the upper portion of Sarah's esophagus of an attempt to insert an endotracheal tube. He found notes showing the tube was successfully inserted, but that's not what he found. He said it was possible that during resuscitation and moving her around, part of the tube was dislodged. The tube would normally go into the trachea but the esophagus is near the trachea and it appeared one attempt at intubation had gone into her esophagus. Internal injuries from intubation would be located in the throat and the esophagus if the tube was not placed in the trachea where it belongs, but he found no evidence of bruising or tearing where the tube would have gone. There was also no tearing of the epiglottis, the flap of cartilage that closes off the trachea when swallowing.

He went on to remove the thyroid gland from the thyroid cartilage area and found a hemorrhage in the muscle covering this. A diagram was placed on the screen and Uptegrove pointed out the trachea, cricoid cartilage and where he found the hemorrhage.

Arnold then placed a photo on the screen showing the area from the diagram below the hyoid cartilage, but the actual larynx was removed and Uptegrove pointed out deep reddish hemorrhages and said this was not from intubation. The intubation tube goes into the esophagus or trachea, and neither had injury. "Those injuries did not come from the endotracheal tube, and that's a fact," he said.

His opinion was that either some type of compression force or generalized blunt-force injury to the neck caused the hemorrhages he found. He told the jury he's done hundreds of autopsies and this hemorrhaging is not associated with CPR.

With the amount of hemorrhaging inside her neck, Uptegrove thought it was important to see if there was any more on the posterior so he examined the interior of the back of her neck. A photo was put on the screen showing the back of her neck, with gloved hands exposing the muscle and interior of the neck. He made a deep incision from the base of her skull to her upper back and found hemorrhaging in one localized area that, in his opinion, was caused by blunt-force trauma, not by the strap that held the intubation tube in place. Another photo was put up showing the top of the spine. He said there were no injuries to the spine, vertebrae or deep muscle tissue. The bruises in this area were localized and superficial, and caused by either compressive force or blunt force but he didn't know which.

He said when a young person dies, if there's no obvious cause of death such as a gunshot wound, the next likely cause could be a drug overdose so they wait for toxicology tests. Sarah's tests didn't indicate any presence of alcohol or drugs or anything that would have caused her death. There was also no evidence of any disease or defects that would have contributed to her death and there was nothing in her medical records to indicate a cause of death. His opinion of the cause of death was drowning. Scene investigation, medical history, autopsy results, ER and EMT reports and speaking with family members are considered when making a ruling on cause of death. He said that he has to make two rulings; the cause of death which is drowning, and the manner of death; WHAT caused her to drown.

He identified Sarah's medical records from her admittance to Bethesda Arrow Springs Hospital and her medical file from Group Health Assoc., her primary care facility. From her medical history, the only thing he found abnormal was a cholesterol level of 203, 3 points over the recommended level, but that would not have contributed to her death. When Sarah was 10 months old she was referred to a Dayton cardiologist for a heart murmur, but according to the report, she had a "functional murmur" and was in good health otherwise. Uptegrove explained that a murmur is an audible sound therefore he could not have detected it but he didn't see the separation that is caused by a murmur during the autopsy. Her medical records didn't show any indication of a heart problem or irregular heartbeat.

He said the bruises to her scalp and neck were the main factors in determining her manner of death. When there is interior neck muscle hemorrhaging and petechial hemorrhaging, he has to consider blunt-force trauma and those aren't typical for drowning. He also stated that force to the front of the neck, whether compressed or blunt could restrict air flow.

Uptegrove said the initial autopsy was done on Aug. 12, 2008, but a second one was done on Aug 15, 2008 by Dr. Werner Spitz and it showed hemorrhaging and dark bruising on her neck. A photo on the screen showed Sarah's body from the V-cut on her chest up to her head [eyes and mouth open] which had been sealed back from the first autopsy. Some jurors did not look at the photo.

Another photo of Sarah was placed on the screen like the previous one but from a different angle. Uptegrove pointed out reddish bruising on the front and left side of her neck and a smaller bruise on the right side of her neck. He said the bruising on the left side is consistent with the IV attempts but the other bruise on the front could have been from blunt force and the bruise on the right side could be from grabbing her neck and squeezing because it was the size of a thumb. Uptegrove went on to explain that if the heart isn't pumping blood through veins and arteries any longer, the blood begins to pool because of gravity, but he added that blood hemorrhaging as depicted in this photo would defy gravity.

John Arnold then read an excerpt from Dr. Werner Spitz's book about the carotid sleeper hold that reduces blood flow to the brain and causes loss of consciousness and Uptegrove agreed with his description. He added that the hyoid bone wasn't broken as it normally is in strangulations.

Uptegrove then explained that pruning of hands and feet was often found in drowning victims and the warmer the water the faster it developed. It begins to develop in about 30 min, but sometimes can be seen quicker. He didn't see any pruning on Sarah and it still would have been present the next morning when he did the autopsy. When someone dies, rigor mortis causes the body to stiffen and it sets in on smaller muscles first. Medical textbooks say it can set in from one to four hours. Dr. Spitz's book said it can develop in 30 minutes but it depends on environmental factors such as heat, cold, humidity, etc. Once it develops, it takes about 12 hours for the body to become fixed, or stiff, but after 36 hrs, the muscles are more flexible again. Uptegrove agreed that if the intubation attempts were difficult, it could be due to rigor mortis setting in.

He said that he has autopsied adults who have died as a result of seizures but they have a history of seizures. Sometimes they bite their tongues or defecate. Sarah had no history of seizures and there was no sign of an anatomic defect in her autopsy.   According to Dr. Spitz's book, about 300,000 people die each year from sudden cardiac death but, according to Uptegrove, about 90% have significant blockage, and others have enlarged hearts, such as athletes.

Arnold placed a photo on the screen of the bathroom and tub prior to its removal from the house. Uptegrove said he looked at photos of the bathroom, and also examined the bathtub. He started to explain how the edge of the bathtub could have caused injuries, but was stopped by a sustained objection.

Arnold then asked him about defensive wounds, which Uptegrove said can be on hands or arms. “The absence of fingernail marks on the skin doesn't mean there is an absence of internal bruising” is stated by Dr. Spitz in his book and Uptegrove agreed.

There was nothing in Sarah's records to indicate a genetic problem so he saw no specific reason to order genetic testing. His opinion is that falling asleep did not contribute to her death because she had significant injuries. His opinion is that she drowned but not from natural causes. Her manner of death was homicide. Arriving at a decision about the manner of death is based on information and inconsistencies about the scene, interviews with family members about health history, and lack of a disease in progress. Nothing further.

Cross Exam: Lindsey Gutierrez

Gutierrez began by asking if he was board certified by the State of Ohio and he admitted he was not, but he took the forensic pathology exam in 2004. She then asked why he's not board certified and he said board certification wasn't required for his job so he decided not to pursue the anatomic pathology certification.

She asked if board certification would pay more and could he get jobs that he otherwise could not? She said without board certification it showed his lack of experience and other places wouldn't hire him. John Arnold objected loudly and the statement was stricken from the record. Uptegrove agreed that a Fellowship, which offers hands-on experience for doctors in training, is done after a residency. It also offers specialized training in a specific field and some doctors do a residency or fellowship and some do both. He said he helps train fellows, but they aren't assigned to specific doctors. Fellowships in the coroner's office usually last about a month. When asked if he's ever done an autopsy in Indiana, he said no because he doesn't have a medical license in that state.

Uptegrove said Warren County is his part-time job, but his full time job is in Montgomery Co. Guiterrez asked if, in 2008, he did approximately 315 autopsies but he said he couldn't recall. She then asked if he remembered his testimony from the first trial in 2009 when he testified that he did about 315 total autopsies in 2008? He replied that he didn't know off-hand if those were the correct numbers but keeps a record of all of them and could provide that information.

Gutierrez then asked him if he's a member of the National Association of Medical Examiners (NAME) and he replied yes. There is a week-long training session every year in the fall and he has attended 3 out of the last 5 yrs. They meet to present information from forensic journals, share information about cases they've done, update members on new scientific information and present paramedic training updates. Uptegrove said he didn't have to take a test to join the organization but he's familiar with

their standards.

Gutierrez then read one of their standards which said that if 250 or more autopsies are done in a year, coroners start to cut corners. If the autopsies done exceed 350, it leads to mistakes and errors in judgement. Arnold objected/sustained.

Gutierrez then asked him if he was aware of any changes to paramedic training but Uptegrove replied that paramedic training wasn't a hot topic at NAME meetings. He agreed that information from paramedics have a lot to do with death investigations and it's important for him to know what they do and how they do it, but he has not been to any training seminars on CPR or intubation.

He agreed that he is not trained in CPR, has never been an EMT or paramedic and has never done an intubation, but he saw one done, once during medical school. He was certified in CPR while in medical school in the early 1990's but let the certification expire.

Sarah's autopsy was done at the Montgomery Co. coroner's office and it took longer than an ordinary autopsy because of her injuries and due to the "nature of the case" and "being suspicious from the git-go." He agreed that during the autopsy he stopped and pointed things out to Det. Braley, but didn't remember any specifics. He reported everything that he found externally and internally but did not list on the report that Det. Braley and Doyle Burke were in attendance during the autopsy.

He reviewed Spitz's autopsy report and agreed that he wouldn't list ribs that were cut open or damage made to the skull because those procedures are routine. Gutierrez then asked, "Is it routine to slice someone's liver?" and he replied "No". He agreed that he didn't make a notation of it so Dr. Spitz didn't know about it until he found it during the second autopsy. Uptegrove said it wasn't his responsibility to call Spitz and tell him.

A photo was put up of Sarah's left arm and Gutierrez called his attention to the hemorrhaging asking if it could be from an IV. He said he didn't see an IV stick on the left arm at the time of his autopsy, but agreed that hemorrhaging can be seen.

He started the autopsy sometime around 8 a.m. the next morning, Aug. 12, 2008.   Gutierrez asked if he had the EMT run reports at that time and he said he had them but he didn't look at them until later. He also didn't have any of her medical records from her GP. Gutierrez asked if he received them a week later, but he replied he couldn't remember. He was sure, however, that he didn't have them at the time

of Sarah's autopsy. He spoke briefly with Sarah's mother and brother the day after the autopsy, and they gave him some details but not complete information about Sarah's health. When Gutierrez asked if they told him that she had a sleeping problem, Arnold objected. Uptegrove hadn't made a final determination of death but told Det. Braley that he was leaning toward homicide. When asked if he knew the arrest warrant was signed on Aug. 13, 2008, Arnold objected again/sustained. Gutierrez asked if he spoke to Ryan or any of Sarah’s friends, and he replied, "No". He said Doyle Burke told him that Sarah had sleeping issues.

A photo was put up showing Sarah in a hospital gown with the tracheal tube still in and Gutierrez asked what the strap around her mouth was made of and he replied he wasn't sure. She asked if it was strapped tight, and he replied, yes, the goal is to keep the breathing mask from moving around. He said the strap did not create the bruise on the neck.

A photo of Sarah's scalp was put up, showing a bruise on the crown of her head. He said it looked like it was from blunt-force rather than compressive force, but he couldn’t date the bruise and couldn’t say the bruise was severe enough to knock her unconscious. There was no skull fracture and no brain hemorrhage. He confirmed that she was wearing pink toenail polish and she had a French manicure on her fingernails.

Gutierrez asked if he was familiar with hemodilution where water thins the blood and increases the volume of the circulating blood? He replied that he was familiar with hemodilution but it would not create a fluid overload. Gutierrez then reminded him that when he testified in the second trial (p.119), Clark asked him the same question and he said then, "It could create fluid overload, yes." He then agreed that increased fluid with pressure, would bleed more than if you did not have an exaggerated amount of water. Gutierrez asked if hemodilution played a role in this case and he replied that it was a fresh-water situation and would certainly be consistent with hemodilution but he didn't measure the blood/water levels.  

A photo was shown of Sarah's arm with a large dissected bruise from Dr. Spitz's autopsy. Uptegrove said it wasn't that large when he saw it 3 days earlier, but the changes are the result of blood vessels breaking down, making it look worse. As blood settles, vessels become engorged and as the blood vessels break down, blood leaks out. Decomposition begins to take place all over the body if the person isn't embalmed yet.

Gutierrez showed a photo of Sarah's uterus, and points out a hemorrhage. Uptegrove said that he drew blood at the time of the autopsy and that's when the hemorrhage occurred. He used a large, 90cc syringe and several pulls were done on the plunger to get a good sample. The blood in the photo came from inside the syringe as the plunger was pushed and pulled several times. Another photo of the back side of the uterus showed more hemorrhaging that was caused by the blood drawn.

A photo was shown of Sarah's chest with the Y-shaped skin folded up over her face and Gutierrez pointed out a hemorrhage asking if it was from the IV stick to the left side of her neck. Uptegrove said that part of it was. Another area was pointed out and Uptegrove agreed that it was at the clavicle notch, beneath the collarbone.  He explained that a vein can be notched, punctured straight through or partially through when trying to start an IV. He agreed that CPR is intended to get blood moving through the circulatory system but he's not sure how efficient it is. Gutierrez asked if it could be 30% of normal, but Uptegrove wasn't sure. He thought it was less than that. He agreed that if a vein is punctured, while chest compressions are going on, blood will leak out of the vein. The same goes for crushed capillaries; more leakage.

Another photo showed Sarah's larynx and Uptegrove pointed out hemorrhaging in the front and middle on the outside. There were no injuries inside her throat. The thyroid gland is a U-shaped organ but there's very little muscle or tissue covering the bones, cartilage and glands. He said he's aware of the Sellick maneuver or cricoid pressure as it's also called. Pressure is applied to the cartilage to help reveal the vocal chords so another medical person looking down the throat can attempt an intubation. He wasn't familiar with the name Sellick maneuver but he knew about the process.

He hasn't done any research regarding how strangulation compares to CPR injuries. Referring to Sarah's case, he was asked if he looked into the comparison of strangulation and intubation and if they could cause the same neck injuries. He hasn't read any studies comparing the two but it "could cause different types of trauma". He didn't visualize anything like that happening but admitted it wasn’t impossible. He didn't inquire about the skill or training of EMTs who worked on Sarah, but was aware that it was a difficult intubation. He was asked if he knew that two attempts were made by an EMT who had only done two prior attempts, and two attempts were done in the back of a moving ambulance, but Arnold objected/sustained. He agreed that he's seen chipped or lost teeth, bruises at the base of the tongue, bruised epiglottis and hemorrhaging inside the larynx after intubation attempts. He's also aware that some life-saving efforts can leave bruising similar to strangling. Tracheal or esophageal rupture is possible, but he's never seen them. He also hasn't seen superficial or deep muscle hemorrhaging from intubation but agrees it's possible. There are gaps between each ring of cricoid cartilage and it's possible that an EMT could injure that area if they didn't know what they were doing. He's not aware of any neck studies but agrees someone has probably studied it.

When asked if he's ever autopsied a 24-yr-old who had 5 intubation attempts, he said he can't tell how many times each patient had been intubated. Since he's not there when they are doing it, he must rely on EMT reports, but the record he got from the EMTs didn't list the number of intubation attempts.

Moving on to the brain, Uptegrove said he wasn't exactly sure how many tissue slides he collected to have analyzed. He usually collected two from the cerebral hemisphere and cerebellum. If he finds any abnormalities, he'll collect more. Gutierrez asked if the brain was "mushy" when he conducted the first autopsy and Uptegrove replied that it had a "gelatinous" consistency to it. When asked if he waited for it to firm up, he replied that he didn't usually wait, but he agreed it's easier to cut the brain when it's firmed up. He took samples while it was in a spongy state.

Lack of oxygen [hypoxia] affects the brain and liver failure, drowning and strangulation are some of the reasons. Seizures come from varied parts of the brain and that's usually determined by a seizure history. He agreed that some people have a seizure that have never had one previously. Gutierrez asked if he would consult an expert for further review and he replied, yes, he has done so before. When asked if he could have found proof of seizures in the brain, he replied, "I'm not a seizure expert."

Uptegrove admitted he did not take out the specific portion of the brain that could possibly show evidence of having a seizure for the first time. Gutierrez asked if there are 14 sections that can be looked at to rule out if someone had a seizure, and Uptegrove replied, " I wouldn't agree with that." Gutierrez then asked if he consulted a neuropathologist and he replied "No".

He was asked if he tested the hypothalmus gland which produces a chemical associated with narcolepsy, but he didn't know the hypothalmus was associated with narcolepsy and he never heard of the chemical.

There are a number of causes of sudden cardiac arrest, but they can't be detected in an autopsy because they are electrical in nature. If the person is dead, there's no electrical activity so he has to rely on the information he's provided. Uptegrove said he's heard of Long QT syndrome and there are genetic tests available but they're expensive and take a long time to get the results. He doesn't just order tests when there's no evidence or family history that the test is necessary but he agreed that no family history is needed for someone to drop dead of an arrhythmia.

He confirmed that he did not have the results of the toxicology report when he talked to Sarah's family, when he signed off on his report, or when he determined it was "homicide". He said it wasn't a legal definition but a medical one and there's a different definition to law enforcement.

Uptegrove said he would not rule a death a homicide just because of what the police told him. Gutierrez then brought up a case that he testified in, from Scioto County in 2007, State of Ohio vs. Walter Young. In that case, the victim, Louella Ridley was an elderly woman who had a piece of clothing wrapped around her neck and he found hypoxia injuries. He said he couldn't remember the specifics but she was in the hospital, then a nursing home and then died. Uptegrove said he contacted a neuropathologist in Cincinnati.

Gutierrez read the previous trial's testimony about the elderly woman:

Attorney: "Oh so some cop told you she was strangled? That's how you determined strangulation?"

Uptegrove then: "Yes, I wasn't there at the scene myself, I have to rely on the police."

Attorney: "You made a medical conclusion because of what someone told you?"

Uptegrove then: "Yes".

Gutierrez then asked if that man was acquitted in that case but Arnold objected/sustained.              Nothing further.

Re-direct - John Arnold

Arnold asked if he was hiding the fact that the two detectives were at the autopsy and Uptegrove replied that this wasn't a sinister plot to hide their identity. He didn't know that Dr.Spitz was doing an autopsy until after it took place. Dr. Spitz never called him to discuss his results.

He didn't search for Ryan to question him when he spoke to Sarah's family because he didn't know where Ryan was so he could talk to him about Sarah prior to the autopsy. Prosecutors asked Sarah's mom and brother to contact the coroner and they gave him information.

Arnold asked Uptegrove if he's observed pruning during an autopsy and he replied yes, sometimes hours or days after the death. About the brain slides, he said the coroner's office submits tissue samples, about the size of a penny and pieces of each organ for microscopic examination. They are kept in a preservative bag and the rest of the organs are placed in a bag and kept with the body when it's given to the funeral home. Uptegrove wasn't aware if Dr. Spitz ordered any genetic tests on Sarah.

Re-Cross: Lindsey Gutierrez

Gutierrez pointed out that Spitz ruled "undetermined" for manner of death and then asked Uptegrove if he was aware that Spitz requested his assistance. Uptegrove replied that he wouldn't try to tell him how to do his job out of professional courtesy so he never made contact with Spitz.

Nothing further.