The Body | 8

A warning to our listeners, this episode contains discussion of mental illness, domestic abuse, suicide, decomposition, and death. The doctor in this case ruled her cause of death, mixed drug intoxication, and the manner of death is suicide. Okay, actually, before we start, I was thinking about this as I was driving home last night, the fewer and all with codeine. I think it's really hard to take 30 as an accident. Like, 30 pills does seem like a lot to me. It is a lot. And so there are two huge math errors in this situation. That introduces another layer of uncertainty. And to call something a suicide, I need to feel pretty certain. I was so ready yesterday to believe that that could have been an accident. And I think it still could have. But 30 pills is a lot of pills. I really don't believe she killed herself. She was there one day and then all of a sudden she didn't show up. Have we uncovered a conspiracy indirectly? Too many unanswered questions. She was scared. She was alive after they said she was dead. uh oh this looks like prescriptions didrax duracef phentermine theormol that's the drug she overdosed on yikes it's actually a list of prescriptions that were given for destruction turned into a pharmacist to destroy after her death maybe we should ask steve about um Yeah, if he took any of her medications to get destroyed. He said he put them all in a plastic bag. Yeah. But that was listed, what, like 15? 16, 17, 18, 19, 20, 21. So 21 pill bottles. And he said he had put hundreds in a plastic garbage bag, so. Yeah. If you had to sort of ballpark guess the number of bottles, how many would you say? 200, 200, 300, probably. I took a black plastic garbage bag. it was at least heavy enough to half the bag was full. Okay, so this looks like a letter from her doctor to Milton Adams, the Justice of the Peace. Dear Judge Adams, In follow-up to our phone conversation this morning regarding the unexpected sudden death of Sue Kogan Knight, I am forwarding the synopsis of her medical care. I have been her primary care physician since May 25, 1985. She has been seen variously for illnesses, injuries, weight loss and depression. She was on continuous estrogen replacement therapy because of a complete hysterectomy due to endometriosis back in 1983. And she had been on Prozac in the past for some previous episodes of depression. She was not currently taking the Prozac because she was not currently depressed. When I saw her last on April 4th, 1996, she had made a routine appointment in her attempt to lose some weight. And I could tell things had changed in her life. She had gained a She said she was glad she had made the appointment because the day before she had come down with a sore throat, a dry cough, and headache. Okay. So she made the appointment to lose weight. And it was just a happy accident. Yeah, she got the flu. At the visit, she had normal vital signs. She was in no acute distress and no obvious pain. The diagnosis at the time was upper respiratory infection and left occipital lymphadenopathy that was secondary to some scratches behind her left mastoid region that she had inflicted on herself inadvertently just in scratching, which had subsequently become mildly infected. So that was what Haley said was on her. Sort of like the back of your head, neck behind your ear. Yeah. It was not serious in appearance. She had also requested medication to assist in her weight loss, which she was to take after she had finished her antibiotics. She was examined for breast cancer since her mother had died from breast cancer. Unless something happens later on, if she was terminally ill in some way, she didn't want me to tell you that's what she's got cancer. No abnormalities were found, and she was advised to get a screening mammogram and to return to the clinic if she had any problems with her medications or if any complications arose. Okay, page two says, we had no further contact with Sue until we heard that she had passed away at her home. As many others, we are saddened by this unexplained loss and are awaiting the autopsy results to determine what had caused this basically very healthy young woman to pass away. She was approximately 43 years old, I believe at the time of her death, and was in good health for most of the 11 years that I have treated her. There had been an episode of possible meningitis a year ago, which was evaluated at the hospital and proved to be viral in nature. There had been a question of a breast mass, which had been evaluated and found to be benign. Other than those episodes, there were no other serious threats to her health, of which I was aware. Once again, if you have any specific questions or a need for any more information, please do not hesitate to contact me. My name is Dr. Erin Barnhart, and I am currently the chief medical examiner for Galveston County in Galveston, Texas. The term medical examiner can mean slightly different things depending where in the country you are. But here, at least, a medical examiner is a forensic pathologist, and a forensic pathologist is a medical doctor who has then done subspecialty training in anatomic and then forensic pathology. That's interesting that it changes depending on where you are. It does. And the reason for that is that throughout the United States, the medical legal death investigation system is really a patchwork. So here in Texas, for example, the larger cities and then some smaller cities like Galveston or some smaller counties are covered by medical examiner offices. And then obviously Texas has a lot of rural, less populated area. Chances are you're not going to have a forensic pathologist in those areas. So in Texas, those areas are covered by elected justices of the peace. And in cases where they determine that a forensic autopsy is necessary, they will have an arrangement with usually the closest medical examiner's office. And they will transport folks to those larger offices for exams as needed. Oh, that's so interesting. That answers a lot of questions I already have about Sue's autopsy in particular. I'd love for you to walk me through Sue's autopsy report. But first, I was wondering if there's anything that stood out to you while you were looking it over or anything that you found particularly noteworthy. I don't think so. I mean, I think what I would say about this autopsy report is that it's not terribly noteworthy. It's a fairly standard report, right? So the very first page that says manner of death pending and cause of death pending, usually something needs to be filed after an autopsy, right? And if you don't know the cause yet, you then have this pending piece of paper. This piece of paper would be sent to, for example, the justice of the peace. It basically lets the JP know, we did your exam, but we don't have the results yet. We have to do some additional studies. And then if we move on to the next page, this is where the actual body of the autopsy report begins. It starts with the viewing of the outside of someone's body. It looks like Sue was 63 inches tall, 135 pounds. Her hair color was brown, also described as long and slightly wavy. She had like blondish silver hair. Natural blonde, blue eyes. She was dirty blonde. She was green in. It looks like she did have some evidence of decomposition, not unusual. And then after that, the next section is the internal exam, where the internal areas of the body and internal organs are described. All right, now I have some specific questions for you about things that stood out to us when we read through this report. Sure. One of Sue's friends told us that she had a missing tooth. She did. I want to say, if I'm looking at her, so I guess it would be on her left side and upper. Is that indicated at all? And would it normally be indicated in an autopsy report like this? So it says the teeth are natural and in good condition. This is probably doctor dependent, but we are usually not doing any sort of in-depth dental exam or description unless somebody is unidentified and we are using dental records to identify them. But usually we're not going through and saying, oh, this single tooth is not there, for example. Got it. So it would necessarily be unusual if she was only missing one tooth for it to be listed this way as natural and in good condition. Exactly. Is there an indication in the autopsy of how long Sue was dead before her body was discovered. They said that she had been dead four days when they found her. I had talked to her a day before that, so I knew that wasn't right. So it tells us that her date of death was April 11th, 1996. And then in parentheses, it says found. That's a common way to indicate that her date of death was probably prior to that, right? For most investigational agencies, if the date of death is not known, the date found is what's used. Based on her state of decomposition, which is described as being early, I think it's probably safe to assume that she had been dead from between one to three days before she was found. The length of time that somebody has been dead is a complicated issue. In the past, and I'm glad to see that it was not done in this case, But definitely as recently as the 70s and 80s, it was not uncommon for forensic pathologists to put some type of estimated, not only day, but time of death in their reports. That's no longer done anymore. And it shouldn't be. And it really never should have been. Because it's too much of a guessing game. Here in Texas, somebody who is in the heat or in an un-air-conditioned space can start to decompose in a few hours. Versus someone who is in a cold climate, it may take them days to get to that same state. So simply looking at the outside of somebody's body and saying, oh, there's a little purge fluid or the skin's a little discolored here. therefore they died 18.5 hours ago. You just can't do that. There's myriad other factors besides external temperature that contributes to the decompositional rate. And once you're past a certain point, your best bet for knowing when somebody died are circumstantial indicators like when did they last pick up their mail? When did the neighbors see them? When did they last send a text message or post on Instagram? I mean, these days, those are your most reliable indicators of really when somebody died. So it's not a very exact measurement, but you're saying that in this case, he didn't really do what was what might have been typical at the time, which is guess, basically. Yes, that's exactly right. The doctor in this case did not guess the time of death, which I'm very grateful for. But, you know, this was in 1996. And so for the most part, this practice had fallen out of favor by that time. And this is the time of death estimates that used to be done are really a perfect example of the things that shows like CSI get wrong, right? Yes. Yes, are really misrepresented to the public because the public has this idea that we can stick a thermometer in somebody's liver and then know the exact time that they died four days ago. And it's just, it's utter nonsense. You said that he lists the level of decomposition as sort of early. Yes. We have heard a rumor that when they found her, her body was described as liquefied. He said that when they arrived, she was pretty well liquefied. And my theory about that is they made arrangements with a cadaver. They didn't expect her to be found as soon as she was. I think it's probably a misunderstanding. We're talking about early, moderate, and advanced decomposition from a scientific perspective. Someone who is in the early stages of decomposition can still look to a person who is not forensic trained. They can look awful. I mean, they can look very frightening. And so to that person, they're going to say the decomposition was severe. Maybe they're using terms like liquefied, right? Yet to us, and scientifically speaking, that's still an early state of decomposition. For us, advanced decomposition is a skeleton. Was there any indication that Sue had cancer at the time of her death? My buddy that she was dating, he said she didn't want me to tell you that she's got cancer. No. Okay. Okay We had sort of heard that as a rumor but we hadn found any actual records of it So I was just curious if anything stuck out to you in that regard No The caveat there that I would say though is that there a few kinds of cancer that we aren good at saying grossly One of those for example would be leukemia So if you talking about something that doesn't actually form a tumor proper, that's something that we wouldn't necessarily have an indication of at the time of autopsy. you looking at this document how do you believe that the cause of death was determined so it looks like in this case the cause of death was based on the toxicology testing so cause of death the choices for cause of death and how to word cause of death are basically infinite manner of death, though, you only have five choices. So your choices for manner of death are natural, suicide, accident, homicide, or undetermined. The doctor in this case ruled her cause of death mixed drug intoxication, and the manner of death is suicide. Now in drug-related deaths, those cases are almost always either going to be accidents or suicides. Accidental versus the suicidal drug overdoses can also be hard to figure out. Generally speaking, indicators of suicidal overdoses are going to be things like toxicity with drugs that are not typically abused. So overdoses with, you know, your bottle of prescription medications versus cocaine or heroin. Other indications might be that, for example, a bottle of prescription or over-the-counter medication is empty. Other circumstantial things that are extremely helpful are obviously things like suicide notes. If somebody has sent email or text messages to loved ones describing what they're about to do, that is obviously enormously helpful. So those are all things that need to be taken into account when this manner of death ruling is made. And then the toxicology report said that her death was mixed drug intoxication due to specifically those 30 fioranol with codeine tablets. How would that have been determined? Well, in the past, it was not uncommon, similar to the time of death approximations that used to be given in autopsy reports. It was not uncommon to try to estimate how much of a drug somebody might have taken. I believe that this has really fallen out of favor now. this is not something that I would ever attempt to do. Again, there's too many variables at play here. What if, for example, the person didn't take all the pills at the same time? What if there was some post-mortem redistribution of that drug, especially in somebody who's decomposed, that could lead to an artificially slightly elevated or lowered blood level? This estimation of pill number is not something that I would ever attempt to do, but it was not an uncommon thing for doctors to do at a certain time. But again, I think when you are making the ruling of suicide, you know, that's not something to be taken lightly. It has a lot of implications. I think probably for that reason, some of these calculations were done to try to support that ruling, right? To say, we're not making that ruling lightly. We're not saying this is somebody who took three tablets instead of their usual one tablet. So I think that these calculations and these estimates were probably done with the best of intentions. I'm just not really confident in their accuracy. So then if that much of the drug was in her system, does it make sense to you that that would indicate intentional overdose? I think it's definitely suspicious. But, you know, assuming somebody is familiar with this medication, knows how many they should be taking, and is, you know, of reasonably sound mind, when you have levels this high, again, it's not, you know, you took one pill versus two pills. It's a really significant difference. When you send out for a toxicology report, who comes up with the ruling? So the only person that can sign a death certificate is a medical doctor, with the exception of elected officials like JPs and coroners. Now, once the medical examiner makes that ruling and that death certificate is signed, it depends on the jurisdiction where you are, but death certificates can be amended. You know, if new information becomes available in a case later, a death certificate can be changed. So that kind of explains to me, basically, we've heard that there were two death certificates for Sue. But what we actually have here is an original death certificate that says pending and an amendment post-toxicology report. Right. And actually, the State Department of Vital Statistics requires, I'm not sure what the timeline is, but they have a requirement for you have to file something within a certain number of days, even if it's just pending. You know, there has to be some sort of a placeholder. The funeral home also uses that to sort of make arrangements. And so there are a lot of people that depend on that death certificate to get the ball rolling for certain things. So even if you don't know the exact cause yet, you still need to get something filed. And would it be unusual for the autopsy to have been completed, the toxicology samples to be sent for testing, and then the body to go ahead and be cremated while that testing was still being performed? That's not unusual now. And in autopsy cases, we will often keep a very small piece of each organ in case we need to do additional testing later, in case we need to look at something underneath the microscope. It's why we take photographs at the time of autopsy, because we don't want to keep people waiting. I mean, it could potentially be a couple of months, and that could obviously be super disruptive for families who are trying to do burials if they want to have visitations and viewings and things like that. It had been almost three weeks since the death. They're not letting them loose the body. It's 12 weeks before we even got anything, and it was a bag of ashes. We talked to a medical examiner. Her name was Dr. Erin Barnhart. and she was so much fun to talk to, first of all, but she also just gave us a whole bunch of good information on basically how normal Sue's autopsy report actually was, which just kind of underlines for me what we've discovered in all of our expert interviews so far, which is just like, if you're not an expert, all of these things seem scary and weird, but as soon as you have that expert knowledge, they're all just standard fare. I honestly find that such a relief. that so little was remarkable or that so little really flagged for her or like seemed wrong to her. That's what we want, you know, like we want people to do their jobs correctly and we want everything to make sense to the experts. Totally. And one of the things that I asked her about specifically was this rumor that we've heard that when police discovered Sue's body, it had been sort of liquefied. Really, her answer to that was one of perspective. She basically said that to a normal person, seeing a dead body in any state of decomposition is horrifying and traumatic, and they don't look good. Do you know what I mean? They look pretty rough. But to a medical examiner, that's still really early state decomposition. Like what was mentioned in the autopsy, this bit of purge fluid and stuff, that's still considered early decomposition because she said to a medical examiner, advanced decomposition is a skeleton. So it makes sense to me that the experience of seeing her in any state of decomposition would have been very upsetting and could have led to this liquefied idea, especially if she had been in her house for a while. And I did actually talk to Dr. Barnhart about the potential timeline of death versus discovery. You know, we've always had questions about this four-day versus three-day versus one-day timeline. And when I asked her about how that would have been determined, one of the things she said is that it really comes down to circumstantial evidence, basically, because, and this is my favorite thing that she said, she said a lot of people watch shows like CSI and think that you can stick a thermometer in a liver and determine down to the minute when someone passed away, and that's just not the case. So the time of death, really to me, it makes sense that that came directly from her neighbors who called in the wellness check. And just to clarify, the date and time of death listed on the autopsy is April 11th at 3 p.m., but it does specify that this is when her body was found. So there's no officially documented timeline where they say how long she had been dead before she was found, other than that they note in the police report that her neighbors said they hadn't seen her since the 8th. So yeah, it seems like it truly is all based on word of mouth. Her neighbors said that they hadn't seen her outside in three days, so the rumor becomes that she officially died three days ago, even though that's not necessarily true. Especially knowing what we know from Dale about how when she was sick, she just really wanted to be alone, didn't want to be bothered. Like, there's no telling how long she was just in her house being sick. And, you know, Pat, her co-worker, having talked to her the day before, if he didn't tell police that at the time, if he didn't tell that to Milton Adams at the time, then they may not have known and just gone with the information they had in the police report, which is her neighbors saw her several days ago. Another thing from the autopsy. So I know Pat mentioned that he wondered if the body they found might not have been Sue. But in the autopsy report, they mention a scar on her lower left arm. And Sue actually mentions that same scar in her visa application from 1976. So that to me is a pretty clear confirmation that this body did belong to Sue. Yeah, I agree. That feels like pretty solid evidence. and after talking to the former U.S. Marshal, I feel like the cadaver theory is sort of off the table. One thing that Dr. Barnhart wasn't able to explain really was why Steve would have had to wait for 12 weeks to get Sue's ashes. When I asked her about it, she said that delay would have likely been on the funeral home's end. And I've reached out to the funeral home, and they said they don't have her records from that far back. There was also a separate crematorium in this case. I called them. They won't release any of their records without a subpoena. But also, I don't know why Steve would have gotten the ashes at all if the funeral home was the one that flew them to Stonehenge. Yeah, me either. Except that maybe those arrangements weren't made until later. For me, the tricky thing here is that we can't verify through records any of these things, really. If Steve did have to wait 12 weeks for ashes, that is a longer time than expected. But we also have no paperwork saying when exactly Steve received these ashes, or that he had them before they were flown to Stonehenge, or that they were flown to Stonehenge at all. So honestly, my feeling is that even though we can't specifically explain this 12-week waiting period, we also don't know for sure that it really happened that way. I agree, but I will say Steve does seem to remember it pretty vividly. Like, it is a detail that stuck with him. So whether it's truly strange or not, it was definitely strange to Steve. I was also looking back over the police report, specifically the section that mentions the medications that were confiscated from Sue's house. It says in the report, quote, the medication was located in the living room and bedroom areas. This medication was checked through the EMS crew through the hospital, end quote. So that's what I assume this list of prescriptions is, that it would have come from the pharmacist who ended up destroying them. And then it says, quote, the majority of the medication was for weight loss. However, one medication, a Digex 50 milligrams, was believed to be for a heart condition, end quote. Actually, Digex is one of the amphetamines. It can be prescribed for weight loss. It's an appetite suppressant. And that seems to be the case for Sue, according to this document from the pharmacy. So another weird little Claire Claire. My question is, if they confiscated some of her medications, why not confiscate all of them? Like, why were there still so many pill bottles around for Steve to fill a black trash bag with? Right. I mean, we can't ask the police because they've declined to be interviewed. But I think we might need to ask Steve because, honestly, I'm wondering if the ones that he pulled from her house were actually empties. But then some of the ones on this list from the pharmacist are empties, too. So that still doesn't fully explain it. Like, if they took some empties, why not all of them? Why would there still be so many left at her house? The only overlap I see there would be that the police report specifically says that the medication on this list was located in the living room and bedroom areas. And Steve said that he found those other bottles in the bathroom. Yeah, I think we just need to ask Steve because it does feel like a contradiction. I also find it really weird that the police report mentions some of the medications specifically and not others. And they don't mention the pills that she supposedly overdosed on, which is the fiorinol with codeine. Right. Which suggests to me that the bottle itself wasn't noteworthy. Like, I imagine if it was spilling open or on her nightstand or something, it would have been mentioned in this report. My name is Dr. Stacey Hale, and I am first and foremost an emergency medicine physician. But I also am a medical toxicologist. and a medical toxicologist is somebody that specializes in poisons, specifically treating and managing poisoned patients. So we are the experts on how drugs manifest in a human being. And part of what I do as a medical toxicologist is I review a lot of autopsies for medical legal situations. But the vast majority of what I do is for the Department of Justice mainly looking at federal drug crime And I also review a number of high murder mysteries When you looked over Sue autopsy report did anything strike you as unusual Yes. And let me preface that by saying that I have reviewed many, many, many hundreds, if not thousands, of deaths that are poisoning-related. With that in mind, what I would say is probably one of my most major pet peeves in reviewing autopsy reports as it relates to toxicology findings is to look at these concentrations of drugs that are found post-mortem and make some sort of conclusion just based on those levels. And just to recap, in this particular autopsy, the medical examiner looked at the post-mortem toxicology findings and extrapolated to not just what might be a level in a living person, but then somehow did some kind of magical calculation in Harry Potter land to come up with the fact that this was exactly 30 faeorinal tablets and thus hence heretofore was a suicide. And you disagree with that? I do. Can you explain why? Sure. So let's just say that you took some kind of drug, any drug. And because you're alive and your heart is beating, your blood is mixing all over your body. And then while you're still alive, if I was wanting to check a blood level of that drug, I would draw your blood and send it to the laboratory and I would get some number of what that concentration is. whether you draw that blood level from a vein in your scalp or a vein in your neck or right smack in your heart or in your toe, that number should always be about the same within some laboratory error because it's being mixed together because your heart is beating. But when you die, everything stops. Your heart is no longer beating and all the blood just kind of stops right where it is. It's kind of like musical chairs and the music stops and everything freezes. And then what happens is part of the putrefaction process, meaning that as your body starts decaying, cells in your body burst open. And so whatever is inside those cells, because drugs don't just stay in your blood, they go into your brain cells or your heart cells or your fat cells. When those start bursting open and they spill into different compartments in your body, you're going to get different numbers based on how close to the blood that tissue is. So in other words, in a dead person, you could potentially draw in the same scenario a blood level from your scalp vein, your neck vein, your heart, your femoral vein, your toe vein, and get completely different answers. Whatever is a blood level in a living person does not extrapolate to a dead person. wow that's huge that feels huge well and it is huge because i have seen medical examiners say oh this number is xyz and because this number is so high that means that they died from this drug this medical examiner actually took it to another level which they not only compared it to a number in a living person, which you're not supposed to do. But they even went as far as to determine how many pills that could have met. And so there are two huge math errors in this situation. So particularly because this was in 1996, how common would this kind of backwards extrapolating math have been back then and how common is it now? Well, I still see from time to time medical examiners say that a concentration is a lethal concentration. I have not seen anybody in the 15 or 18 years that I've been doing this to actually go as far as to determine the number of pills that someone could have taken. Now, in 1996, in full disclosure, I was still in medical school. So, you know, it's hard for me to say what was standard practice in 1996 for this kind of thing. But I still think that even then, this was requiring quite a bit of junk science calculations to come up with this sort of determination. I think that in this particular situation, just looking at what was found in this toxicology testing, the best kind of answer is that it was undetermined, especially because let's just say that she was having such a bad headache that she was taking more pills than she should have. That would be an accident, right? And so how do you know that it wasn't an accident versus a suicide? So this brings up something that I've always considered sort of a weird detail. The pills that are listed in this toxicology report are fioranol with codeine tablets. And the report claims that the levels in her blood indicated she took 30 of them. But we know from another report that when the bottle was removed from the scene, it still had some pills left in it. And to me, if it was intentional and she decided to take her own life by overdosing on these pills, it just seemed to me like maybe she would take all of them. Like that has always just seemed a little bit odd to me. So I agree that if somebody was intentionally trying to hurt themselves, that they would take all of them. But more importantly, if you look on her prescription list, these Fiorno tablets were actually prescribed in December. They were prescribed on December 20th, so, you know, roughly four months earlier. So presumably, she took those pills from time to time whenever she would have a headache. So I think just considering the fact that there are a certain number missing is not helpful when you know that this prescription had been prescribed four months prior. The thing that I guess I'm confused about is that the actual cause of death is listed as mixed drug intoxication. Can you explain what that means and how that would have been determined? So mixed drug intoxication is a catch-all phrase that medical examiners use when more than one substance is found post-mortem. And in general, I feel like that's intellectually honest to call it mixed drug because I don't really want the medical examiners picking and choosing what drug they think is the one that caused death. So when you look at what's present postmortem, you see salicylate, codeine, eutalbatol, caffeine, and morphine. Those are five different substances, but they all came from the one pill. And then there was fentermine, which is from her weight loss medication. So there were several different weight loss medications found at her home. And even though they're not exactly like methamphetamine or amphetamine, they are in that amphetamine class and can be dangerous from that standpoint. Now, the things that are found postmortem in her were drugs that she was prescribed. So you would expect to see those whether she had committed suicide by an overdose of them or not. This is not like finding arsenic. Just because these substances are present doesn't tell you anything. You expect to find them. Based on the amount of medication in this toxicology report, would that have been a lethal dose? If we knew that she had taken 30, then that could certainly be a cause of her death. But we don't know how many she took. And you can't go backwards from these levels to determine how many were taken. So that's where the controversy is. You cannot interpret post-mortem toxicology in a vacuum. You need to correlate that with scene findings, witness statements. You have to look at the totality of the evidence. And, you know, I always reserve the right to say, I don't know. But I think that in this particular situation, based on what I've seen, saying I don't know is fine. And so to call it undetermined would have been perfectly appropriate. Thank you so much for talking to us again, Dr. Barnhart. I really appreciate it. Sure. So since we last spoke, we interviewed a toxicologist who said pretty emphatically that there was no way to determine the number of pills taken based on post-mortem samples, which is something that you brought up in our interview too, that that's not really a kind of calculation that you would do. So do you agree with what the toxicologist said, that there's really no way to make that calculation? I do. I do agree. And I think really that's why you don't see people doing that anymore. I honestly don't know exactly how long that particular practice lasted. I obviously was not practicing at that time, but my impression is that it was a bit of a fad, frankly. But yes, I agree with the toxicologist. I think there's too many variables and too many problems with that type of calculation to be of any real value. So since the amount of drugs in Sue's system at the time of her autopsy doesn't tell us definitively how much or how little medication she took, what effect, if any, do you think that has on the official ruling of suicide as the manner of death? I think it has a big effect. When we're talking about suicide, there's a lot of human behavior involved in that, right? A lot of nuance about our attempts, you know, at prediction of human intention. And thus, it's fallible and really highly subjective. So it's an area that I always try to be really careful. And I try to, I really want, you know, when I'm making a ruling of suicide, I really want to have as much evidence as possible that that's really what was going on. So the levels matter. And so uncertainty about those levels certainly introduces a layer of uncertainty and one that's frankly a bit hard to get past without some other pretty clear evidence that that's what was going on in this case. It can be hard looking at these old cases, especially back then, right? When, you know, it's not like people were exchanging electronic email back and forth or keeping information on servers. It may have just been that the doctor, you know, had a phone call from the investigators that, oh, yeah, this lady is suicidal and depressed. And he may have had some other impressions of the case that maybe weren't officially documented. Yeah. And unfortunately, this was in kind of a rural area. And so it was handled by a justice of the peace, sort of like you mentioned last time. And we just don't have a ton of insight into what that communication might have been, right? We know that they were in contact to an extent, the JP and the medical examiner, just based on a few records in the inquest. But it seems like you're exactly right. Most of it would have been over the phone. So our records are limited. Yeah, it definitely complicates things because the medical examiner in this case really has no legal authority to investigate the case because it's a JP county. It's not a medical examiner county. So what that means is that that forensic pathologist or any forensic pathologist is entirely dependent on the JP for investigational information. And ultimately, you know, the JP is the one that is signing the death certificate also. And they can put whatever they want on the death certificate, even if it's totally different from what the doctor puts on the autopsy report. So it does introduce a level of complexity into any death investigation. One of the things that you talked a little bit about last time was that an empty bottle is pretty solid evidence or is pretty suspicious and compelling evidence. Since that time in our research, we have found that the medication she took, which is fiorinol with codeine, still had some pills left in the bottle, actually. What are your thoughts on that? So my thoughts are that much like the uncertainty about drug levels, that introduces another layer of uncertainty. And to call something a suicide, I need to feel pretty certain. Also, another absolutely valid manner of death classification is undetermined. We don't like to do that. Forensic pathologists hate to call cases undetermined. It's very unsatisfying. You know, we like to be able to provide an answer. But nonetheless, it's the appropriate manner of death classification in some cases, and it may just be that this is one of them. Firstly, they told us it was complications of her having the flu. It sounds weird that someone was sick with the flu and then their death is a suicide. And then it was complications. She was taking medication and they drank liquor with it. I knew that she had been sick and they said well you know she threw up during the night and aspirated and that choked her She didn shoot herself Okay Figured she shot herself This is yet another example of a different theory about how she died because there was so little clarity around her death Before talking to Dr. Barnhart and Dr. Hale, I really was feeling pretty confident in the suicide theory, but that was because of the 30 pills calculation. So if that's not real, if 30 pills can't be trusted, I don't really know what to think. The thing I keep thinking about is that, like Dr. Hale said, you have to look at the totality of the evidence. So if we are being told that this math cannot be trusted, then that would mean that the other things surrounding her death become significantly more important. Exactly. So this feels like a good time to talk about my conversation with Dr. Prahlo, the original medical examiner who performed Sue's autopsy. Yes. Tell me everything. Well, there's not really a lot to tell, honestly. He didn't want to go on Mike. And remember, he's done hundreds, if not thousands, of autopsies since then. And this one was almost 30 years ago. So he didn't remember Sue's case specifically. So he was just going off of our copy of his autopsy report from 1996. He did not do the drug level calculations himself. He said that would have been done by a toxicologist and he would have just received their results. And we've tried to track down the toxicologists who actually did Sue's report and haven't been able to get in touch with them. Dr. Prawlow also said the drug levels indicated in the toxicology report would have been consistent with overdose. But he said something similar to Dr. Hale that those types of calculations aren't really done anymore for all the same reasons Dr. Hale described. Right. Like she said, even if those levels were high, there's no way to know if they're accurate in a post-mortem body. The numbers can't be trusted. Exactly. But he did stand by the suicide decision because the toxicology report was only one piece of it. And all of the other circumstantial factors Haley just mentioned would have informed his recommendation as well. And that information would have come from the investigation done by the Justice of the Peace. Right. And Milton Adams, the justice of the peace, has declined to be interviewed. But just in terms of what we have in this inquest report, which we inherited in the briefcase, and it's basically a bunch of paperwork the JP collected while looking into Sue's death, we do have this note that Sue wrote, which we've been calling her depression note. August 21st, 1995, at 9.45 p.m. The thoughts race around in my head. The radio plays. A thought. I'm tired of hanging on. I'd like to let go. Yet if I really wanted to, surely I would do so. Yet I really want to let go. I'm just afraid it won't succeed. I'd hate to wake up again. I'm tired of it all. I argue that it's just chemicals in the brain out of balance, but that doesn't help, even if it's true. I don't want to cry. I don't feel like crying. I'm not sad. I'm not lonely. I'm not miserable or desolate. I'm just tired of hanging on. I really have prayed to be taken, but it falls on deaf ears. I always wake up and get up and go on. But hell, I'm really tired of it. There isn't really much reason for anything, good or bad. It's all just blah. Yuck. So why am I wasting my efforts writing? Hell, no one will ever read it. No one can do anything about it because there is nothing wrong. I'm just tired. Blank. Empty. Full. Tired. Pointless even writing. God, please, please take me. I'm done. Don't leave me here anymore. I want to go to sleep and not wake up anymore. Please. it is pretty rough and i mean i can definitely see how it could point to suicide as an answer and clearly the jp felt like it was important enough to include it in this file but it was written about eight months before she died and also in this inquest report we have this letter from her doctor, who of course also declined to be interviewed. But in this letter from just after she died, he says specifically that Sue wasn't currently taking antidepressants because she wasn't currently depressed. So, yeah, I just wonder what else led to that determination. Because again, this could be me being a layman speaking on expert things. But to me, a note written eight months earlier and a quote-unquote not currently depressed woman by word of her doctor does not a suicide make. Yeah. I mean, the depression note in my mind is specifically not a suicide note, right? But Dr. Prawlow made it seem like it was really a process of elimination based on what was found by the JP and the police. So she was found alone in her home with the doors locked in her own bed no evidence of foul play. So, you know, not a homicide, not a natural death because she didn't have any kind of terminal illness. She wasn't that old. She was just 43. So, you know, that kind of narrows down the possibilities. So I could see that kind of making suicide more plausible just by that evidence. The big thing that I sort of gained from talking to Dr. Barnhart and Dr. Hale was that not being able to trust the meth that led to the idea that she took 30 pills doesn't necessarily mean that her death wasn't a suicide, but it also puts accident back on the table. I think that that really changes things for me. I think a lot of the reason that people in Sue's life were unable to accept her death and unable to accept things as told to them is because they felt like suicide was so out of character, which again, we've talked about before, like how do we categorize that? How do we define that? But I just wonder if accident is any more palatable or acceptable. Yeah. Honestly, accident, I mean, what could be more tragic than a suicide? I don't want to downplay that possibility and how horrible that is, but accident weirdly feels sadder to me that she wanted to live and that she couldn't. I don't know if it's more palatable or better because I think most people who love being alive are terrified by the idea of dying. But like, I don't know if it's more palatable, but if it's more true, I think that matters, you know? Yeah. It really sucks too because like, It's very possible that that determination was completely reasonable based on the combination of everything. We just don't necessarily have all of the records that indicate what those elements were that combined to suicide as an answer. Right. The Athens PD told me they gave me everything they have. But since this case is so old, it is possible that there was more that has since been destroyed. And since neither the Athens PD nor the Justice of the Peace will speak with us about Sue's case, we just don't have a full picture of how Milton landed on the suicide ruling. Because like Dr. Barnhart said, it was ultimately Milton's call. It falls on the JP's shoulders to sign the death certificate in a case like this. Which brings me to another roadblock that I wanted to mention. Although we do have a copy of the JP's inquest file, that copy was originally requested by Steve Barksdale in 2018. So I requested a new copy of the file directly from the office just to make sure that what we have is complete. And the JP districts have shuffled since Sue died. But I've talked to several offices now, and none of them can locate this file. They've told me that it's not lost. It is misplaced. That sounds like the same thing to me. Yeah. To be fair, it is a paper record from almost 30 years ago. So they're digging through filing cabinets for me. But it's been several months now, and it seems like the original file is not where it's supposed to be. And it is concerning to me that no one has been able to track it down. But we don't necessarily have any reason to believe that the copy we have is incomplete, right? Well, that's the thing. I just can't say for sure. You don't know what you don't know. God, that is so frustrating. I really, really was hoping that looking more closely at the body would give us actual answers. and it fucking didn't. It just fucking didn't. I will also just say, going back to the question of how this manner of death ruling was determined, I asked Dr. Prahlo about the possibility of an accident, and he said that if there was no indication that she was incoherent or incompetent, there'd be no reason to think it was an accident. So it's almost suicide by default because there was no reason to think she would have been unaware of how many pills she had taken. That doesn't make sense to me. Like, what if she was just distracted, not paying attention, took her medicine again? Or like, sick. I've definitely been sick enough to not remember if I already took my medicine. Again, I am not a doctor. But that idea just doesn't leave much room for just like simple human mistakes. Which in my mind brings us back to undetermined as maybe the best answer, which is what Dr. Barnhart suggested. Dr. Prowlow didn't mention that option, and I reached back out to him to ask about it, but I'm still waiting to hear back. Yeah, Dr. Hale said that too, that she would have probably gone with undetermined based on the information in the autopsy. I find it so incredibly poetic too, that like basically what she was saying, what I heard her saying was a best answer I can give you and not best in terms of like, I'm out of other things to say, but the truest, best, number one, correct answer I can give you is actually, I don't know. And like, that just feels so true for so much of this. You know, that's after looking at thousands and thousands of pages of research. Sometimes the best answer is still, I just couldn't tell you. I just don't know. Yeah, but I can totally understand the impulse of the people who are given the answer, I just don't know, to not accept that. Totally. Especially when you're taught that you can stick a thermometer in a liver and say, you know, exactly to the hour when somebody died. You know, like when you are taught that there's somebody out there who is smarter and knows better than you and they don't. That's awful. It is awful. And on top of that, there are still so many unanswered questions. Like, that letter from her doctor mentioned that she had previously had viral meningitis. And meningitis affects your spine and brain and can give you headaches. And that, plus her scratching the back of her head to the point where it broke skin and got infected, and her taking all of this headache medication, like, to me, that seems like it goes together. When there's so much weird shit, it just, it should mean something. Do you know? Like, those things should go together. They should point to something. Yeah, but those pieces don't necessarily go to the same puzzle. And to make them fit together, you have to stretch farther and farther from the truth. Like, I don't think we should say that just because she had a scratch and took headache pills and used to have an illness, that her death was definitely an accident or not. Which is again why both of these doctors pointed to undetermined as an answer. There's really no way to know and then guessing has huge implications. Absolutely. Like if Sue's death hadn't been ruled a suicide, then she would have received more of her life insurance money. Not to mention the social stigma around suicide, especially in a conservative part of Texas in the 1990s. And it reflects so much on your life and makes your loved ones rethink who you are. I get that and I know you're right. I know you're right. It just still sucks. It sucks to be on either end of an I don't know answer, especially when there's still so much that just doesn't make sense. Next time on Undercover of Night. She was there one day and then all of a sudden she didn't show up. Like, I don't consider myself a naive person. But I mean, clearly the course of this project has convinced me otherwise because I just, I'm believing everyone at every turn. Memory is not like a video camera. It's not like we capture everything and then can retrieve it accurately. Even when we have this strong feeling, it doesn't necessarily mean we get every detail correct. She still remembered that you were listed as the executor several years later in 1993. And she never told you about it at all. Never knew anything about her. Let's just take a moment to appreciate that at this point, we've got a woman with about six different names that we know of, a missing death in quest, and we can't even seem to nail down the name of the street she lived on? Like, this is the squishiest story ever. Undercover of Night is an Apple original podcast produced by Spoke Media and Castleview Productions. Our writer, host, and showrunner is Jenna Burnett. Associate producers are Lucy Huang and Reyes Mendoza. Our researcher is Haley Nelson. Our consulting journalist is Bob Sullivan. Mix, sound design, and original music by Will Short, with additional music from Universal Production Music. Story consulting by Brigham Mosley. Executive producers are Caroline Hamilton, Sharita Lynn Solis, Ted Barnhill, Heather Mansfield-Jernigan, Alia Tavakolian, and Keith Reynolds. Special thanks to Dr. Aaron Barnhart and Dr. Stacey Hale for sharing their expertise with us. If you have any information on Sue Knight, you can email us at infosuenight at gmail.com. If you or someone you know needs support, go to apple.com slash here to help for resources. Follow on Apple Podcasts. Thanks for listening.