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Andy PhD DABT
Andy PhD DABT, Toxicologist
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Experience:  Board certified with 17 years in research or consulting
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Thinking about this, Im still a bit mystified!

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Hi Andy
Thinking about this, I'm still a bit mystified! If Chris didn't take the P as capsules, he must have taken it as a liquid. The P must have been the pink liquid, they have made a mistake saying no drug found in his stomach. If it had passed beyond the stomach, they would have found drugs in his bowel somewhere?

If he had taken capsules, the remnants of these would have been found in his bowel somewhere?
Am I right in thinking that the H2S triggered a massive asthma attack? Given the low levels of hydrogen sulfide, is it possible he might have survived if he had been properly medicated for his asthma? Yes, I know it's all academic now and the outcome is that he did die. But, I can't help but think that if it had been different for him....Probably it's a silly question.
Would you object if I were to submit your letter of opinion to the Coroner, if need be? I think that your LOP differs from the pathologist's report in that it mentions asthma. I'm not too sure whether an English Coroner's Court would accept it, what do you think? Thank you a million times for your Answers, though!
Lauren

I. rooorur w
Submitted: 3 years ago.
Category: Health
Expert:  Camille-Mod replied 3 years ago.
Hi, Andy is currently off line but I have emailed him to let him know you are waiting for him. When he gets back on line he will assist you. Thank you for your continued patience:-)
Camille- Moderator
Expert:  replied 3 years ago.
Hi Lauren,

Sorry it took so long to get back to you, I haven't been feeling good. Chris could have taken the pentobarbital by capsule. Capsules are made of gelatin and dissolve very quickly and will only look like protein when the stomach contents are analyzed. So just because there were no capsules in his stomach does not mean he hadn't taken any capsules. The pink fluid might have been from the capsules or a liquid or something else. You can't easily tell how he took it for sure, if it was capsule or liquid. They did test the stomach contents for drugs and reported nothing. They did not test the intestinal contents for drugs, only the stomach. I don't think the negative findings in the stomach contents were a mistake, it is more likely that the pentobarbital had moved on into the intestine since it was in his blood already and few drugs are absorbed in the stomach. The pink color could have been some minor bleeding, there was some damage to the stomach wall, which possibly was a result of his crohn's disease. So I think either he had taken it long enough before he died that it had moved into his intestines or he had taken it by injection. There was no needle or syringe reported at his flat so I don't think that was it. The police did say they found pentobarbital, they just didn't say in what form it was. Maybe the police can tell you, though it sounds like they aren't very helpful.

You can send my letter of opinion to the coroner if you want, that is fine with me. I don't know if they will accept it, I am not a medical examiner.

The autopsy report said there was some mucus in the lower portion of the bronchi which suggests an asthma attack had occurred, but no mucus plug was found, so it probably was not fatal, and there was congestion of the respiratory tract, which could be from breathing an irritant. This could mean that there was an irritant effect (from the hydrogen sulfide) which also aggravated his asthma, but I don't think you can say the asthma was what killed him since the mucus didn't completely obstruct the bronchi. I would say the asthma may have contributed to his death, but that ultimately the hydrogen sulfide and probably pentobarbital was what killed him. The asthma does not seem that bad and there are cases of people dieing with blood levels of thiosulfate (from hydrogen sulfide) at the same level as what Chris had. So hydrogen sulfide decreases the body’s ability to use oxygen and decreases the respiratory rate so the body can't take that much oxygen in. Pentobarbital decreases the respiratory rate too, which further decreases the amount of oxygen the body can take in. So the hydrogen sulfide and pentobarbital can work together decreasing the oxygen in the body leading to death. It is very reasonable to assume that the hydrogen sulfide and pentobarbital by themselves would have killed Chris even if he did not have a history of asthma. I don't think having his asthma under control would have saved his life. Knowing that hydrogen sulfide can cause death very quickly and that it takes at least 30 minutes for the stomach contents to enter the intestine and no pentobarbital was found in the stomach, but was found in the blood, then I think what happened is that Chris took pentobarbital well before he created the hydrogen sulfide. Probably to help cause death, reduce his anxiety about committing suicide, or for both reasons. Then he created the hydrogen sulfide, probably after he started to feel the effects of the pentobarbital (which means much of the drug had been moved to the intestine, since that is where it is absorbed into the blood). Because he had pentobarbital already in his body by the time he breathed in hydrogen sulfide, it may not have taken much hydrogen sulfide to then cause his death, which could account for the low thiosulfate blood levels.

I hope this helps.

Take care,
Andy
Andy PhD DABT, Toxicologist
Category: Health
Satisfied Customers: 108
Experience: Board certified with 17 years in research or consulting
Andy PhD DABT and 8 other Health Specialists are ready to help you
Customer: replied 3 years ago.
Hi Andy

My apologies for the long delay - I have had a lot to think about! The doctors are saying, chris was depressed but there is a lot more to it than that. Enquiries are still ongoing, I am sure I will have more questions for you after Tuesday (22nd November), the date of the Inquest.

One further question please? The doctors stopped treating Chris' Crohns disease, saying it was not possible to do this without a blood test. I know there are other medications for Crohn's which don't require blood monitoring. Do you know these?
Also (this is two questions, sorry!) I understand from a friend who has had Crohn's for many years that there are "markers" which show whether Crohn's is active, thus obviating the need for blood tests. Do you have any ideas on these? Thanks for all your help! Lx
Expert:  replied 3 years ago.
Hi Lauren,

Yes there are medications that can be taken for Crohn's disease that don't need blood tests. These medications include the 5-aminosalicylates, such as sulfasalazine or mesalamine which release 5-aminosalicylate to specific parts of the intestine. So these are similar to aspirin in that they have anti-inflammatory effects, but they should not require monitoring. However they are useful only in mild to moderate cases, in severe cases of crohn's the immunosuppressants are really needed. There are also antibiotics that can be used, but they are more for cases with coexisting infections. Anti-diarrheal medications can be used for suppressing diarrhea and intestinal cramping, such as propantheline, dicyclomine, or hyoscyamine and they would not need blood tests, but they treat the symptom, not the cause - inflammation. Corticosteroids can be used for severe cases, but they have lots of side effects from long term use (such as bone thining, cataracts, diabetes, hypertension, and others), so they generally are only for acute attacks and not long term maintenance therapy.

For severe cases of Crohn's you really need the immunosuppressants for long term therapy, such as azathioprine, methotrexate, 6-mercaptopurine, natalizumb. Immunosuppressants are anti-cancer drugs, they slow cell growth or cause cells to die. This effects primarily the fast growing cells such as the bone marrow which make all the blood cells, including the white blood cells which are immune cells and cause inflammation. So the drugs work by causing immunosuppression by lowering the number of white blood cells. So the problem is that before you can start taking them you need to first see how many white blood cells the person has, if it is too low then they can't be treated with immunosuppressants or their white blood cell count will go dangerously low and they will be at risk for all sorts of infections, much like an AIDS patient. Then once therapy is started they have to keep monitoring it and adjust the dose if the white blood cell count gets to low, so the blood tests are needed long term too.

There are markers for inflammation which can be used to follow how active Crohn's disease is, but it is not specific for crohn's disease, it is usually used to monitor treatment to see if it is working. These markers include C-reactive protein and orosomucoid. They are blood tests and getting them won't rule out having to get blood tests required for taking immunosuppressants, both blood tests would be done.

Since Chris' doctor was going to put him on immunosuppressants he must of had a severe case, which would be consistent with him having to have had surgery earlier, so my guess is that the aminosalicylic acids drugs aren't powerful enough for the severity of his disease and that this was the only class of drugs to turn to. Doctors don't want to have to go to them because of the immune suppression is risky for infections and treatment can lead to a lethal infection if not monitored, so I am sure the drugs that don't need monitoring were tried before, no doctor would start with immunosuppressants unless the patients' disease was severe. So I think Chris could have been put on the aminosalicylic acids along with anti-diarrheal drugs and possibly antibiotics which don't need monitoring, but my guess is that was already tried or he was severe enough to not think that would have been very helpful.
Andy PhD DABT, Toxicologist
Category: Health
Satisfied Customers: 108
Experience: Board certified with 17 years in research or consulting
Andy PhD DABT and 8 other Health Specialists are ready to help you
Customer: replied 3 years ago.

Hi Andy,

 

Sorry to be a pain but if Chris had severe Crohn's, why did the doctors give him nothing instead of the Azathioprine leaving him in agony. It's a circular argument, why didn't they just fall back to the aminosalicylics? I know you don't have this answer, but thanks again! L

Expert:  replied 2 years ago.
Hi Lauren,

Sorry I did not get back to you in time. My infant daughter was sick for about a week and during that week was Thanksgiving and Black Friday, so I was not able to check my e-mail for several days. When I tired to answer your question I was locked out, so I am answering through this older question posting.

You are right to question the inquest, it seems ridiculous that they came up with the conclusion that Chris swallowed some chemicals that produced hydrogen sulfide and that is what killed him. It is possible to do that, but very unlikely. Yes Chris did have some damage to his stomach, but depending on what chemical he supposedly swallowed I would imagine that he would have gotten more severe damage, or that he would stop drinking the chemicals after he started and it burned his throat or tasted really bad. The chemicals that can be used to make hydrogen sulfide gas are not made to be palatable. It depends on the exact chemical, or really mixture of chemicals that Chris took, but I would think it would be very unpleasant to swallow, cause him to throw up, and make it hard to carryout the suicide that way. Also the reaction of producing hydrogen sulfide generates heat which would further damage the stomach and be unpleasant.

Further the toxicology report said that they did not detect anything in the stomach, only some pink fluid. They knew they were looking for hydrogen sulfide, why did they not report having detected any sulfates or sulfur in the stomach contents? If hydrogen sulfide was generated in the stomach some gas would leak out as burps (it would be unpleasant to generate gas in the stomach without burping and if not enough gas was generated to force him to burp than it probably wasn’t enough to kill him otherwise) and could be inhaled, if that were the case then lots of it would still be in the stomach at the time of death and would likely be detected during autopsy just on the rotten egg odor alone. Possibly it could have moved into the intestine and cleared the stomach before he died, but if enough gas was generated to cause death, it would likely cause a lot of burping and breathing it in would have been the cause of death which can occur pretty quickly.

All the recipes for suicide by hydrogen sulfide are for creating hydrogen sulfide gas that is then breathed in, I have not seen any reports of people swallowing chemicals to produce hydrogen sulfide in their stomach and if someone tried it they probably would have vomited up the chemicals. Hydrogen sulfide is detoxified in the intestine to much less toxic sulfates, so more would have to be taken by mouth then by breathing to kill, possibly more then most could stand to swallow and not throw back up.

So the heart of your question is if chemicals can be swallowed that will produce hydrogen sulfide that will cause death. I think it is possible, but very unlikely since it is much less toxic taken by mouth and it would likely be very unpleasant to swallow and not throw up. Taking the relatively small size of the stomach and unpleasant nature of swallowing the chemicals into account I would not think most people trying this would be able to kill themselves. If you are generating enough gas in your stomach to be deadly, you are probably causing enough damage and irritation to the stomach and esophagus to be noticed and to cause vomiting.

Is there a report or some documentation from the inquest explaining their ruling? I would love to look at it. I don’t understand what they base their ruling of swallowing the chemicals on when there wasn’t anything in the other reports to suggest that. The police report only stated that they found “…chemical containers and signs that this male had taken his own life by chemical suicide…”, it did not mention a mixing bucket specifically or something similar, maybe that is the basis of their ruling, but the police report is missing lots of details, not even reporting what chemicals were found, so I am not surprised they didn’t report a mixing bucket.

You also asked why the doctor didn’t treat Chris with the more mild drugs which didn’t require blood tests. Sorry, as you stated I can’t answer that, the only one who can is the doctor who was “treating” Chris. I would think that the doctor would have at least offered the weaker drugs, but maybe they didn’t think it would help or didn’t understand how strong Chris’ opposition to blood tests would be and figured he would come around to getting them done sooner or later. I don’t think the doctor made the correct decision no matter what their rationale, something is better then nothing. That is a question to ask the doctor directly I think. Maybe it was a matter of miscommunication between the doctor and Chris, I don’t know.

I think the inquest was wrong and came up with a bizarre ruling. Suicide by hydrogen sulfide has only been reported to have been carried out by generating the gas and inhaling it, to suggest otherwise would require some pretty compelling evidence and I never saw any in the reports I read.

If you get a report from the inquest I would like to look at it. I don’t know what to say you can do next, I’m not familiar with legal proceedings, maybe you can contest the ruling. Let me know if I can help further or if you have a report from the inquest.

Take care,
Andy
Andy PhD DABT, Toxicologist
Category: Health
Satisfied Customers: 108
Experience: Board certified with 17 years in research or consulting
Andy PhD DABT and 8 other Health Specialists are ready to help you
Expert:  replied 2 years ago.
Hi Lauren,

I see in the message you specifically asked about damage to the esophagus. The autopsy reports, say that the esophagus was normal, so what damage are they talking about? If the large amounts of chemicals needed to cause death were taken by mouth then I would expect some damage to the esophagus as well as the stomach, but that was not seen. Also, either the chemicals would still be in the stomach or they would have moved on to the intestines. The autopsy report says that the intestine were normal, so if there was damage to the stomach, but not the intestine then and the chemicals caused that damage to the stomach, then they would also damage the intestine unless they stayed only in the stomach. The autopsy report said no chemicals were found in the stomach.

Now when people inhale vapors, some of the vapors dissolve in the mucus and thin fluids of the respiratory tract, in this case it would be not as hydrogen sulfide gas, but as hydrosulfuric acid, which is a mild acid and could cause some mild damage, with more damage occurring where prolonged exposure took place. The respiratory tract moves mucus and thin fluids out of the trachea and into the esophagus where it is swallowed. So every time a person breaths vapors, a small amount will get into the esophagus and stomach and could cause some damage, though this likely would be mild compared to damage seen in the lungs.

The autopsy report state the intestine and esophagus were normal, but that the stomach had some damage to it's surface. It then stated that there was congestion of the larynx, trachea, bronchi, and lungs, which are all one continuous path to the lungs indicating mild damage from breathing an irritant. So the respiratory tract showed signs of mild damage, but only the stomach portion of the digestive tract had damage. The stomach damage could be for two reasons, one some hydrosulfuric acid was swallowed while breathing hydrogen sulfide and it only damaged the stomach because it is only a mild acid and needed time to cause damage, so sliding down the esophagus was not enough time to cause damage, or the damage to the stomach is unrelated to hydrogen sulfide, possibly from Crohn's disease, which can effect the stomach. Either way if Chris had swallowed the chemicals I would have expected damage to the esophagus since large amounts of the chemical would be needed which wasn't the case here. There would also be chemicals still present in the stomach or in the intestine and if they reached the intestine they would have cause damage. Instead if only small amounts of the irritating chemicals were swallowed then I would expect to only see damage to tissues in which it came in contact with for a long time, such as the stomach, but not the esophagus, as was seen.

Now congestion, the damage seen in the respiratory tract, could be just from the process of dying, as Chris stopped breathing he stopped getting oxygen to his blood and stopped removing carbon dioxide which is made by the cells throughout his body. When carbon dioxide levels get high, they cause blood vessels to dilate and get larger to allow for more blood flow to the tissue (if the person is alive) which removes the carbon dioxide from the tissue so it can get breathed out in the lungs. So when breathing stopped the cells in his body will remain alive for a short time, producing carbon dioxide, which can't be removed and builds up, causing blood vessels to dilate which causes congestion of tissue. So that is just part of the dying process, however congestion was only reported for tissue of the respiratory tract, larynx, trachea, bronchi, and lung. This suggests that the congestion was caused by something inhaled and not simply from the dying process.

So the evidence points quite convincingly to having breathed in the hydrogen sulfide, not to swallowing chemicals to produce it in the stomach. Further I could not find any case of people swallowing the chemicals to commit suicide, but there are tons of cases in which the chemicals were mixed in buckets to produce hydrogen sulfide gas which was then inhaled to cause death. I can't see how the inquest can justify their findings.

Take care,
Andy
Andy PhD DABT, Toxicologist
Category: Health
Satisfied Customers: 108
Experience: Board certified with 17 years in research or consulting
Andy PhD DABT and 8 other Health Specialists are ready to help you

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