The Education of a Coroner

by John Bateson

  Sammie’s eyes were blistering and his throat no doubt felt like it was on fire. He held his mattress in front of him to stop the spraying, but the COs pulled the mattress down and continued to squirt him. He tried to push them out of the cell—three huge men, each one younger and stronger than Sammie—and for several seconds was succeeding. Collectively the COs were mightier, however, and they got Sammie down on his stomach. Two men pinned him to the ground, with one man placing his knee in the middle of Sammie’s back.

  “Sammie had more than four hundred pounds on his torso,” Holmes says, “compressing his diaphragm. It was the worst possible situation for an older, overweight man to be on his belly with all that weight on him after being sprayed and sprayed and sprayed.”

  Sammie kept saying, “I can’t breathe! I can’t breathe!” but the COs ignored him, thinking that it was a ploy to get them to let up.

  Still with a knee in his back, and his shoulders, arms, and legs held down, Sammie was handcuffed, then leg restraints were applied. As Holmes wrote in his supplemental report, “At about this point Marshall began to exhibit signs of seizure or convulsion, although it was not a violent reaction, mostly described as uncontrolled shaking. There was no vomiting, gagging, or flailing.”

  Sammie was facedown on the cement floor, “trussed like a pig,” Holmes says. One of the female COs advised turning him on his side and this was done, then a litter was wedged into the cell and Sammie was loaded onto it. According to all the COs, Sammie was coherent and communicating with them as he was being carried to the infirmary. Holmes found this highly questionable, however. In talking with other prison staff he was told that Sammie seldom communicated with anyone, and if he did it was widely described as mumbling. Several people said that they had never heard Sammie speak.

  As soon as Sammie arrived at the infirmary, a paper mask was placed over his mouth and nose. His mouth was bloody, and he was known to have spit at prison personnel before. It was unclear to Holmes what everyone in the infirmary did after that, even though each person filed a formal report on their involvement. There were six to eight people tending to Sammie, including three correctional officers (because Sammie was a death row inmate), a nurse, and a physician. Holmes talked with the medical staff, who said that Sammie’s blood pressure was taken twice, but that appeared to be all that was done. His breathing was described as shallow but not labored. Twenty minutes after he entered the infirmary, Sammie was hooked up to an EKG monitor. It showed a flatline heart rate; Sammie had no pulse.

  Holmes found nothing in Sammie’s medical history to indicate a known heart disease, and Sammie had not been on any heart medication while at San Quentin. Holmes determined that the prison physician had access to blood pressure, pulse, and respiration information when Sammie first arrived, well before pronouncing him dead. The doctor didn’t initiate CPR at any time, and Holmes wondered whether Sammie’s seizure was misinterpreted as cardiac arrest.

  Holmes noted that Sammie didn’t appear to have been choked, accidentally or otherwise, to the point of losing consciousness and causing anoxia, a condition in which brain cells begin to die because they lack oxygen. The autopsy showed no abnormalities other than the expected congestion of the mucosal linings of the larynx.

  The one correctional officer whom Holmes wasn’t able to talk to because he no longer was at the prison was the videographer. Seeing a videotape of Sammie being removed from his cell would have been helpful in assessing what took place and the sequence of events. Holmes was told that the camera “malfunctioned,” however, so there wasn’t a tape.

  Two and a half months after Sammie’s death, Holmes received the results of a tryptase test that was done on Sammie. Tryptase is a substance found in the blood, and an elevated level indicates anaphylaxis—an allergic reaction that can cause a sudden and dramatic drop in blood pressure, sometimes with fatal consequences. Individuals have reported eating shellfish and seafood throughout their lives and then, on one particular occasion, they developed an anaphylactic reaction from it and almost died. Sammie’s tryptase level was elevated well beyond the normal range, leading Holmes to conclude that Sammie had an allergic reaction to the OC spray, since no other substance was involved in the cell extraction or in the infirmary.

  During a subsequent and formal coroner’s inquest, Holmes brought to light all of the factors that made Sammie’s death a potential homicide—the excessive pepper spraying, the compression of Sammie’s diaphragm due to all the weight on him, Sammie’s pleas that he couldn’t breathe, the fact that Sammie had no known heart problems, and the lack of proper medical care. Holmes was convinced that Sammie’s death wasn’t accidental or due to natural causes, and it obviously wasn’t a suicide. Neither the police nor the district attorney was willing to file charges, however. Prison officials, in their own investigation, concluded that Sammie died from exertion because he was overweight and his heart gave out. The correctional officers and medical staff were absolved. Holmes ended up saying that the manner of death was undetermined. He felt bad about that, and regrets it to this day.

  “The COs were complicit and the system was complicit,” he says. “I’m not an advocate for inmates or anybody who does something bad, but I’m an advocate for doing something the right way, and they did it wrong. Sammie Marshall didn’t need to die, and he didn’t deserve to die, certainly not under the circumstances of moving him from cell to cell.”

  A lesson Holmes learned early on echoed in his brain. “When the guy with the badge says stand up, if you don’t stand up you’re a bad guy. If the guy with the badge says sit down and you don’t sit down, he feels like he’s being challenged and it escalates from that point. It shouldn’t be that way. What they should have done was have a counselor come and talk to Sammie, tell him, ‘Sammie, it’s going to be better if you move.’ They all knew him, he had been in the system a long time. They knew he wasn’t educated. He wasn’t an idiot by definition, but he wasn’t far from it.”

  Sammie had a brother who lived in the South. When Holmes notified him of Sammie’s death, the brother couldn’t understand it.

  “Sammie’s not a violent person,” he said. It was true.

  “Sammie was a big guy,” Holmes says, “and had been convicted of murder, but other than a few psychotic episodes he wasn’t a threat to anyone.”

  Four months before Sammie died, the California Supreme Court unanimously reversed his death sentence. It was only the second time in five years that the court found grounds to reverse a death sentence on direct appeal (eighty-four death sentences were affirmed during the same period). The basis for the reversal was that Sammie’s attorney, a Long Beach lawyer named Ron Slick, never told the jury that another man had been witnessed leaving the murder scene just before the victim’s body was discovered. Slick also never told the jury that the semen found in the victim’s vagina didn’t match Sammie’s DNA. In fact, Slick rested his case without presenting a single witness.

  After Sammie’s sentence was reversed, he was never informed of it. Letters from his lawyers were returned unopened. Meanwhile, day after day Sammie continued to sit in his cell, rocking back and forth on his steel bed, certain that prison staff were poisoning his food and that his lawyer was conspiring with them. He wasn’t that far wrong.

  CHAPTER 11

  INVESTIGATING SUICIDES

  In the United States, 40,000 people die by suicide every year. By comparison, there are 18,000 homicides in the country annually. The average person doesn’t know it since it’s rarely the subject of news stories, but more than twice as many Americans die by suicide as are murdered. Coroners know it, though. They deal with suicides every day. Some take place in homes, garages, and hotels, while others occur outdoors, in parks and recreational areas.

  The Golden Gate National Recreation Area (GGNRA) consists of 80,000 acres of protected open space, much of it formerly used by the U.S. Army. Unlike other parks, it’s not continuous; rather, it comprises multiple areas that stretch south, from Marin County
through portions of San Francisco and into the northern part of San Mateo County. Included are fifty-nine miles of bay and ocean shoreline, a number of decommissioned army bases, and destinations as diverse as Alcatraz Island and Fort Mason. The bulk of the GGNRA is in Marin County, with the Marin Headlands, Muir Woods, Stinson Beach, Muir Beach, and Tomales Bay among the most prominent locations. More than fifteen million people visit the GGNRA annually. Not surprisingly, it has been the site of numerous suicides, too.

  A seventeen-year-old girl was lying on the floor of a van that was parked in the Marin Headlands. Her feet were hanging out a rear cargo door, a gun was on her stomach, and there was an entry wound in her right temple and an exit wound on the other side. Her body was warm, she was fully dressed, and there was slight rigor and lividity. Holmes found several sealed envelopes in a jacket pocket, displayed prominently. The notes were dated the same day that her body was found and were addressed to family members and friends. One note said that she stole the gun from an aunt’s boyfriend. When Holmes talked to him, he said that he kept the gun in plain view in his bedroom. Another note said, “There was nothing you could have said that would have changed my mind. I wasn’t trying to get back at anyone, and it wasn’t anyone’s fault. . . . I wasn’t as strong as I thought. . . . Forgive me.”

  Mount Tamalpais State Park consists of three hillside lakes and miles of hiking and biking trails, many offering panoramic vistas. When a thirty-seven-year-old woman disappeared after leaving a suicide note for her boyfriend, he called the police in a panic. While sheriff’s deputies searched the area, the boyfriend and two of his friends began looking for her on the 2,700-foot-high mountain. Her body was found sixty feet down an embankment that wasn’t accessible by foot. A police helicopter was used to retrieve her remains. She could have been the victim of an accidental fall, but during the investigation Holmes learned that she had a history of depression, was being treated by a local psychologist, and had attempted to jump from the Golden Gate Bridge the previous year but was stopped. The note she left her boyfriend, which he shared with Holmes, indicated her intent.

  “I’m so sorry to all my family and loved ones,” she said in the note. “Life seems so scary because I feel incapable of doing just the simple daily tasks that most people do to function in life. . . . I wish I could make myself stay alive for you. But I’m drowning, inside, by a lack of self confidence, extreme sense of inability, laziness, and general dissatisfaction of how I’ve conducted myself in this life. . . . I just can’t struggle any longer.”

  Another suicide was of a fifty-one-year-old writer named Calvin Kentfield, who jumped from a cliff at Point Reyes National Seashore. The night before, his backpack was found abandoned at the top of the cliff, and his white 1960 Volkswagen bus, unlocked and with the key in the ignition, was located blocking a fire gate.

  Since it was dark, park rangers contacted the U.S. Coast Guard’s air assistance service to help locate him. The helicopter search was unsuccessful, however, so people returned early the next morning. At 9 A.M., Kentfield’s body was sighted on the beach, 280 feet below the cliff. A rescue party with a Stokes litter—a long, shallow stretcher with sides—went down a steep trail to the beach, retrieved the body, which was nude, and brought it up to the road, where Holmes was waiting. He observed numerous abrasions, befitting a fall from a cliff, and was given a typed suicide note that was on the front seat of the van. The note, signed by Kentfield, said he was tired of living and was going to kill himself. Also inside the van was an unpublished manuscript, plus a book contract with an East Coast publisher.

  Kentfield had written several novels, as well as a recently published memoir. According to the toxicology report, his blood alcohol content was .19—no surprise to Holmes since by now he knew that many suicidal people drink excessively beforehand to dull their senses and overcome self-preservation instincts.

  BROTHER AND SISTER

  Whenever someone dies by suicide, loved ones of the deceased ask, Why? Why did he or she do it? There’s no one answer because suicidal behavior is complex. A variety of social, psychological, and physiological factors are cited. According to the National Institute of Mental Health, 90 percent of the people who die by suicide have a diagnosable mental illness; however, the majority of people with mental disorders don’t kill themselves. Similarly, events such as the end of a relationship, death of a loved one, financial problems, legal issues, or declining health can lead to a suicide attempt, but most people who face these or other personal crises don’t resort to suicide.

  Holmes knew that psychological pain and extreme feelings of helplessness and hopelessness were important pieces of the puzzle. They produced the desire for death, of a release from one’s physical, emotional, and mental anguish. Anytime Holmes talked with family members, friends, or physicians who treated a suicide victim, he asked them about the decedent’s frame of mind.

  The other important factor was developing the capacity to kill yourself. This wasn’t something that Holmes knew when he started, but he came to understand it the longer he was on the job. Through practice and repeated exposure, individuals can become habituated to death. Some suicides, particularly by younger people, seem impulsive, but most victims develop a fearlessness about dying. This results from previous suicide attempts, from frequent witnessing of deaths—one reason why soldiers and police officers have high rates of suicide—and from suicides by family members and friends. It’s aided by having access to lethal means, which becomes the centerpiece of a plan.

  One of Holmes’s first cases concerned the suicide of a twenty-year-old man named Skip. He had tried to kill himself by overdosing on Seconal, a barbiturate most commonly prescribed for insomnia, after his girlfriend had killed herself several weeks earlier overdosing that way. Skip survived the attempt and was hospitalized on a psychiatric hold for seventy-two hours, during which time he refused to see a doctor. As soon as he was released, Skip vowed to continue making attempts until he died.

  Skip had two sisters. Bonnie was three years older and a striking beauty with brown hair and brown eyes. Patty, the oldest, was a reserve in the San Anselmo Police Department. Skip knew that Patty kept a service revolver somewhere in her house; also, she was away much of the day because she worked at a local veterinary office. Patty’s husband, Art, was out of the house often, too.

  While Patty and Art were gone, Skip went to their house. He knew where they kept a key and let himself in. Rummaging around, he found Patty’s gun on a shelf in her bedroom closet. He took a chair from another room into the bedroom, sat down with his back to the closet, and shot himself in the head.

  Holmes responded to the call, which was how he got to know Patty, Art, and Bonnie. All three were beside themselves with grief. After that, Art and Holmes developed a friendship. They had coffee together several times, and generally stayed in touch.

  Art was the one who found Bonnie’s body. It was several months later, and he didn’t call his wife. Instead, he called Holmes. When the call came through, Holmes knew something was wrong. Art was so choked up that he could barely say Holmes’s name, but Holmes recognized his voice. He thought maybe it was Art’s wife, but Art said no, it was Patty’s sister. She had shot herself with the same gun, in the same chair, facing the same direction, as her brother Skip.

  Ever since Skip killed himself, Bonnie had suffered from fits of depression. Three months earlier she had attempted suicide by overdosing on phenobarbital, after which she was hospitalized for seven days. Lately she had been seeing a psychiatrist. Like Skip, she used the hidden key to enter Patty and Art’s house while they were out.

  “I’m not going to tell Patty until you get here,” Art told Holmes.

  When Holmes arrived at the house, Patty was still at work. The house was within walking distance of the veterinary office, and Art decided that it would be best if the two of them went there rather than told Patty when she came home. Art realized that if Patty saw Holmes, though, she would know that something was wrong, so he
told her boss to tell her to come out in back of the office, away from her coworkers. There, with Holmes standing at his side, Art told her that Bonnie had shot herself.

  Patty’s lips quivered and she looked on the verge of fainting. Without anyone saying it, she knew that that wasn’t the whole story, as terrible as it was. She didn’t have to ask her husband or Holmes to know that there was more to it, that Bonnie had killed herself with Patty’s gun, in Patty’s bedroom, just as Skip had done. She could see it on their faces.

  Following Bonnie’s death, Patty got rid of the gun and quit the police force. She and Art kept in contact with Holmes for a while but gradually lost touch. As much as he tried to provide comfort and support, Holmes was a reminder of the twin tragedies of their past. It was easier for them not to see him.

  PAINKILLERS AND HARD DRUGS

  When Holmes started working in the coroner’s office, he had a good understanding of medicine and firearms, which proved invaluable in doing death investigations. One subject he knew next to nothing about, however—and had to get up to speed on fast—was drugs, both legal and illegal. There was only one way to do it, and that was by constant studying.

  “Whenever I encountered a new drug or brand-name variation, I would go to the books,” he says. “The Physicians’ Desk Reference was an amazing resource, before the Internet. Now I can look up almost any chemical compound on my phone, but in the early days that wasn’t an option.”