Alameda County Sheriff's Office Gregory J. Ahern, Sheriff] Coroner Coroner's Bureau, 2901 Peralta Oaks Ct, Oakland, CA 94605 (510) 332-3000 I (510) 382-3033 (fax) Coroner lnvestigator's Report 0 NAME DE DECEASED ILAST, FIRST MIDDLE) TENTATIVE ID 1 UNIDENTIFIED CASE NUMBER lzl- LEE, Paul Wilbert I 201 8-001 43 REPORTED DY REPORTED BY PHONE ND. REPORTING AGENCY REFERENCE NUMBER 7 I I . . 4 Susan Spoehna (510) 357?8300 kindred Hospital 2017-01888 INVESTIGATOR CALL DATE AND CASE TYPE Andrea Golden 1/9/2018 1 1:33 Removal Case DATE AND TIME OF DEATH DATE OF AGE GENDER RACE MARITAL STATUS VETT 1 1/5/2913 9:12 10/7/1968 49 Years Male Black Divorced 1 HGT WGT EYE COLOR HAIR COLOR OCCUPATION EMPLOYER 66 165 Brown Black 1 (Natural deal-11111513ngycaroldmale, identi?ed as Paul Lee, reported by Kindred Hospital. Lee 1 i into cardiac arrest while in at SRJ, while being booked for a DUI. Lee was transported to 1' 1 Preliminary ValleyCare, where a heart stent was placed. Due to coma and uncontrolled seizures following Summary surgery, Lee was transferred to Stanford Hospital. He was later transferred back to Valley/Care, and 1 later to Kindred Hospital, where he died on 010518. NOK noti?ed and made arrangements; Death 3 1 was intitially ?agged as suspicious due to family making false report about the nature of Lee's death; 1 LOCATION OF DEATH LCD TYPE Kindred Hospital Hospital - 1P ADDRESS (STREET. CITY. STATE ZIP) COUNTY 1 1 2800 Benedict Drive San Leandro CA 94577 Aiameda Manner Natural Death Certificate Signed By: 1 Cause A Medical complications tollowmg acute myocardlal Infarction Interval Months 3 - Cause Coronary atherosclerosis lntervai Years 1 Cause interval Cause interval None Other Significant Conditions 1 LEGAL NEXT OF KIN RELATIONSHIP TELEPHONE No. 2 9 1 Paul Lee Jr. Son (408) 618-9274 . NOTIFIED BY METHOD DATE AND TIME I IDENTIFICATION METHOD DATE AND TIME Drivers license 1/6/2018 9:00 LOCATKON (3F INCIDENT AT WORK 11111 5 I ?1 i ADDRESS (STREET. STATE, 20?) COUNW ATE AND TIME OF INCIDENT 1 AGENCY AGENCY PHONE NUMBER 1 OFFICER CHP - Oakland M. Simpson FUNERAL HOME BODY RELEASED To FUNERAL HOME ON n_ Royal Memories Funeral Home 1/17/2018 9:20 0) 5' Fult Autopsy Partial Autopsy Inspection Record Review Inspection w/Specimen EXAM BY V1 Thomas W. Rogers Date Printed Friday, March 16, 2018 Alameda County Sheriff's Of?ce Gregory J. Ahern, Sheriff Coroner Coroner's Bureau, 2901 Peralta Oaks Ct., Oakland, CA 94605 (510) 38-2-3000 (510) 382-3033 (fax) Investigator Narrative Decadent: LEE, Paul Wilbert Case Number: 2018-00143 Investigator: Andrea Golden First Call Information: On January 9, 2018, about 1133 hours, Deputy Bordi spoke with Michelle de Vera regarding the death of her brother-in-law, who she identi?ed to be 49 year old Paul Lee. At the time of de Vera?s call, there was no record of Lee?s death being reported to the Coroner?s Bureau. According to de Vera, on October 27, 2017, Lee had a medical emergency while in custody at Santa Rita Jail. De Vera said Lee was medically transported from Santa Rita Jail to ValleyCare Med ical Center in the City of Pleasanton. De Vera told me Lee was transferred to Stanford University Hospital in the City of Palo Alto, then-back to ValleyCare Medical Center, and was eventually transferred to Kindred Hospital, in the City of San Leandro, where Lee died on January 5, 2018. De Vera told me she believed Lee had no prior medical history except ?bad teeth?, and requested an autopsy be performed on Lee and an investigation to be initiated by the Coroner?s Bureau. (AGZ291) On anuaiy 9, 2018, about l215 hours, 1 (Golden) spoke with Kindred Hospital Nursing Supervisor T. - Houghton. Nurse Houghton told me Lee was pronounced dead, on January 5, 2018, at 0912 hours, at Kindred'Hospital. Nurse Houghton told me she did not have Lee?s medical'records during our conversation and the information she provided me Was based on her limited memory of Lee?s stay at Kindred Hospital. Nurse Houghton said she believed, on October 27, 2017, Lee was involved in a motor vehicle accident while driving under the in?uence of alcohol. Nurse Houghton said Lee was arrested, but was possibly first taken to Santa Clara Medical Center to be cleared for incarceration. Nurse Houghton was not sure about the exact course of Lee?s treatment, where he had been transferred, or the exact dates. of the events prior to his admission to Kindred Hospital. (AG2291) . Medical Summary: 1 (Golden) received California Highway Patrol Oakland report #201701888 documenting Lee?s arrest, on October 27, 2017. The report had no mention of a vehicle accident, or of Lee being transported to Santa Clara Medical Center. The report stated CHP noticed Lee had an expired registration sticker. Cl-lP initiated an enforcement stop by activating their forward facing solid red lights and Lee pulled his vehicle to the side of the road without incident. Lee was arrested for ?Driving Under the Influence? along with other vehicle and penal code violations. Lee told CHP he had taken 6 Norco pills that morning. CHP transported Lee to the Glenn E. Dyer Detention Facility (GEDDF), where he was booked in, at 1 126 hours, without incident. The CHP reportstated Lee did not have any visible injuries during the time of his arrest. (AG2291) According to Alameda County Sheriff?s Of?ce Santa Rita Jail incident report #17-0'1'8919, at 1737' hours, Lee was transferred to Santa Rita Jail (SR3), where he was held in cell About 1803 hours, an SR1 deputy observed Lee experiencing what appeared to be a seizure. Lee was breathing, but was unconscious and shaking. Medical aid was requested. Nursing staff responded, and they found Lee had a Alameda County Sheriff?s Of?ce Gregory J. Ahern, Sheriff Coroner Coroner's Bureau, 2901 Peralta Oaks CL, Oakland, CA 94605 (510) 382-3000 (510) 382?3033 (fax) faint pulse and could not be aroused by an ammonia inhalant. An ambulance was requested, nursing staff utilized an Automated External De?brillator (AED) and administered Cardiopulmonary Resuscitation (CPR). About 1814 hours, Alameda County Fire Department (ACFD) Rig #17 and Paramedics Plus Rig #135 arrived at cell T-2 and continued lifesaving measures. Lee was placed on a gurney and Paramedics Plus Rig #135rtransp0rted Lee to-ValleyCare Medical Center. Responsetime between the-timerof Lee?s medical event to time of lifesaving measures was estimated to be four to five minutes. (AG2291) On January 9, 2018, Deputy Bordi sent medical records requests to Santa Rita Jail, Valley Care Medical Center, Stanford University Hospital and Kindred Hospital. (AG2291) On January 9, 2018, Deputy Bordi received medical records from Santa Rita Jail, which were downloaded into the digital photographs folder for pathologist review. According to the medical records, Lee?s medical history included hypertension since he was 18 years old, chronic alcohol abuse, occasional drug abuse, osteoporosis, hernia, dental pain, depression, bipolar disorder, and chronic back pain. The records stated Lee?s primary care doctor, Webster Medical Clinic Dr McMullan, prescribed Lee Norco on an ongoing basis. The SRJ medical staff had obtained Lee?s primary doctor records, which showed Lee was diagnosed with hypertension, asthma and hernia. The records showed Lee was prescribed 'Albuterol, Cholecalciferol, Gabapentin, Hydrochlorothiazide, Hydrocodone, Metoprolol Succinate, Dicloxacillin, Hydrocortisone, and ibuprofen. The records indicated Lee smoked a pack of cigarettes per day and consumed a pint of brandy and two beers daily. (AG2291) On January 9, 2018, I (Golden) received Lee?s medical records from ValleyCare Medical Center. I placed a copy of the records into the case ?le and a copy into the pathologist packet. ValleyCare records indicated Lee was admitted for cardiac arrest with ventricle fibrillation. A computed tomography (CT) head scan was performed on Lee, which showed no bleeding or ischemia. Admission tests indicated Lee had encephalopathy, congestive heart failure, and ?drug abuse and marijuana? present in an initial urine screen. While at ValleyCare, Lee received a percutaneous coronary intervention (PCI) of the left anterior descending (LAD) artery with a drug?eluting stent. Lee had encephalopathy with concerns for anoxic ventilator. (A6229l) On October 30, 2017, the decision was made to transfer Lee to Stanford University Hospital for continuous electroencephalogram (EEG). (AG2291) . On January 24, 2018, 1 (Golden) received Lee?s medical records from Stanford University Hospital. 1 provided a copy of the medical records to Chief Pathologist Dr M. Ferenc. According to the medical records, Lee was at Stanford from October 30, 2017 to November 9, 2017. The discharge summary stated that Lee?s neurostatus was unchanged, despite receiving 5' anti-seizure medications and continuous EEG- monitoring. Lee continued to be unresponsive, with daily fevers, voluminous tracheal secretions, and the decision was made to transfer Lee back to ValleyCare Medical Center, as continuous EEG monitoring was no longer recommended. Discharge notes speci?ed, ?Patient has very poor prognosis and family is unrealistic.? On November 9, 2017, according to ValleyCare Medical Center medical records, Lee was transferred back to ValleyCare Medical Center, where he continued to be on ventilator support. Status epilepticus appeared to be controlled, and a tracheotomy was performed, but Lee continued to remain unresponsive. Alameda County Sheriff's Office Gregory J. Ahern, Sheriff Coroner Coroner?s Bureau, 2901 Peralta Oaks CL, Oakland, CA 94605 (510) 382-3000 I (510) 382?3033 (fax) The decision was made to transfer Lee to Kindred Hospital in San Leandro on November 16, 2017, for higher level care and to attempt weaning from the ventilator. On January 1 i, 2018, 1 (Golden) received the Kindred Hospital medical records and placed them in the digital photographs folder-for'pathologist review. The records indicated Lee was not improving, and on January 5, 2018, Lee entered Bradycardia and his cardiac changed. Lifesaving measures failed, and Lee was pronounced dead, at0912 hours. On January 24, 2018, about 1320 hours, I faxed a request for medical records to Webster Medical Clinic for Lee?s. primary medical care records. (AG2291) Description of the Death/ Injury Scene: - On January 5, 2018, at 0912 hours, Lee was pronounced dead the Intensive Care Unit at Kindred Hospital, located at 2800 Benedict Drive, in the City of San Leandro. (A6229l) Body Identi?cation: I (Bordi) accessed Cal-Photo and'located Lee?s California Department of Motor Vehicles photograph. I compared the decedent to the photograph and it matched. A copy of the DMV file was placed in the case ?le. (E81879) On January 1 l, 2018, about 1130 hours, I (Meldrurn) received a fax from the Alameda County Central Identi?cation Bureau. A comparison was made between the decedent?s fingerprints and the fingerprints associated with PFN (Personal File Number) ASA914 with the name Paul Wilbert Lee and the DOB 10/07/1968. The ?ngerprints were identified to have been made by the same subject. Next of Kin InvestigatiOn: 1 (Golden) spoke with Michelle de Vera, who told me that Lee was not married. De Vera told me Lee had six. children, some of whom were minors. De Vera refused to provide me with Lee?s children?s names or contact information. De Vera said Lee?s sister, Tanasha Lee, was Lee?s Durable Power of Attorney form. Healthcare. (A6229 1) While reviewing Lee?s Kindred Hospital medical records, 1 (Golden) saw the following [pie were listed as Lee?s children: Paula Lee (daughter), Robert Lee (son), Paul Lee Jr. (son), and possibly Adrian Lee. (AG2291) On January 14, 2018, about 1714 hours, I (Bordi) received a call from de Vera, who said she would email me a. copy of Lee?s Durable Power of Attorney (DPOA). About 1728 hours, i received the email and reviewed the DPOA. The DPOA designated Tanasha as the agent for healthcare. The page where Lee was supposed to Sign the document was blank. The document was notarized in regards to Tanasha?s signature, but I could not locate a signature for Lee. I spoke with Tanasha and she told me Lee?s children gave her authorization for the Durable Power of Attorney. Tanasha said there was no paperwork indicating their authorization. i explained to Tanasha that Lee?s children were the legal next of kin and could sign the authorization for funeral arrangements. Tanasha said she would have one of the children sign the funeral authorization. (EB1879) Alameda County Sheriffs Of?ce Gregory J. Ahern, Sheriff Coroner Coroner's Bureau, 2901 Peralta Oaks Ct, Oakland, CA 94605 (510) 382~3000 (510) 38241033 (fax) On Monday, January 15 2018, 1 (Sobrero) received an email from Royal Memories Funeral Home authorizing Lee?s release from the Coroner?s Bureau. The release was authorized by Lee?s son, Paul Lee Jr. 1 con?rmed Lee could be released and completed the pro?authorization paperwork. Copies of the emails were placed in the case ?le and the file was placed in the ?release rack.? (SS 1832) Other Agency Reports: Refer to Alameda County Sheriff?s Of?ce Santa Rita Jail incident report #1 7-018919. A copy of the report was placed into the case ?le. (AG2291) Refer to California Highway Patrol Oakland report #20170] 888. A copy of the report was placed into the case ?le. (AG2291) Property and Evidence: I (Golden) issued Coroner?s receipt #3 8877 to Kindred Hospital staff for Lee?s body. There was no property associated with this case. (AG2291) Coroners Fees: There were Coroner fees for body 1emoval and body preparation totaling $400 associated with this case As ofMalch 9., 201 1,8 fees had not been paid (AG2291) Investigative Details: On January 9, 20l 8, about 1356 hours, Deputy Bordi and 1 (Golden) a1r1ved at the Kindred Hospital . morgue We were met by Nurse Houghton, who led us to Lee? 3 body I performed a limited external examination of Lee?s body, and found moderate rigor, no visible lividity, purge coming from his nose, and dry skin with a slight, superficial sore on his left foot. 1 saw no sign of obvious visible trauma-t0 Lee?s body. Due to the fact Lee?s death was being treated as an ?In Custody Death,? I placed paper bags over. Lee?s handsper the Coroner?s Bureau policy and procedures. Deputy Bordi took scene photograpjisgg and we prepared Lee?s body for transportation to the Coroner?s Bureau. About 1428 hours, we arrived at the Coroner?s Bureau and processed Lee into the morgu? wiigichw included intake photographs. Scene and intake photographs were later downloaded to a disc and placed into the case tile. On January 10, 2018, about l042 hours, Coroner?s Pathologist Dr T. Rogers conducted Lee?s autopsy. Dr Rogers deferred Lee?s cause of death pending ?Case Review.? On February 8, 2018, Dr. Rogers determined Lee?s cause of death to be ?Medical complications following acute myocardiai infarction, due to coronary atherosclerosis.? (A6229 1) Findings: On Mach 9, 20 8, I (Golden) reviewed this case to determine the manner of Lee 5 death. Based on my investigation and the autopsy protocol, I found the manner of Lee sdeath to be natural (AG2291) Alameda County Sheriff's Office Gregory J. Ahern, Sheriff Coroner Coroner's Bureau, 2901 Peralta Oaks Ct, Oakland, CA 94605 (510) 382-3000 (510) 382-3033 (fax) Supervisor Review: On Friday, March 9, 2018, I (Sgt. Gonzalgo) reviewed this case and found it to be complete. I concur with the ?ndings and approve this case for closure. However, due to the fact the Coroner?s fees are still . outstanding, the case will show ?Closed-Pending Fees? until all fees are paid in ?ill. (NLG5228) .I. a: a} Coroner?s Bureau 2901 Peralta Oaks Court, 2nd Floor, Oakland, CA 94605-5319 DATE: FROM: TO: SUBJECT?new" as I w' Director of Emergency Services Coroner - Marshal A January 10, 2018 Thomas Wayne Rogers, M.D. Case File 2018-00143 AUTOPSY PROTOCOL Autopsy performed upon the body of Paul Wilbert Lee at the Coroner?s Bureau, 2901 Peralta Oaks Court, Oakland, California, on January 10, 2018, at 9:10 a.m. 2) CAUSE OF DEATH: AUTOPSY FINDINGS ANOXIC ENCEPHALOPATHY WITH STATUS EPILEPTICUS (BY HISTORY). GENERALIZED ARTERIOSCLEROTIC CARDIOVASCULAR DISEASE: A) B) D) E) F) CARDIOMEGALY FOUR-CHAMBER DILATATION OF HEART STENT, LEFT ANTERIOR DESCENDING CORONARY ARTERY CORONARY ATHEROSCLEROSIS AORTIC ATHEROSCLEROSIS STATUS POST MYOCARDIAL INFARCTION (BY HISTORY). PULMONARY CONGESTION AND EDEMA. INFARCTION DUE TO CORONARY ATHEROSCLEROSIS. CC: District Attorney Investigation?s Bureau MEDICAL COMPLICATIONS FOLLOWING ACUTE MYOCARDIAL Page 2 Sheriff?Coroner Alameda County Body of PAUL WILBERT LEE EXTERNAL EXAMINATTON The body is that of an African American male appearing the stated age of 49 years. There is a Coroner?s identification tag present on the left big toe. The body is 67 inches long and weighs 179 pounds. The body is presented in a supine position. The body is nude. Rigor mortis is past. Lividity is present over the dorsal aspect of the body. There is the following evidence of MEDICAL THERAPY: l) A.dressing covering a nonremarkable appearing tracheostomy ostia over the midline.of the neck. 2) A dressing covering a probable needle puncture mark in the medial aspect of the right upper arm. 3) A medical band about the right wrist. 4) A_dressing covering a needle puncture mark in the dorsal aspect of the right hand. 5) A PEG tube in the left upper quadrant of the abdomen. 6) Two medical bands about the left wrist. 7) A dressing covering a needle puncture mark in the medial aspect of the left upper arm; There are no blunt injuries noted to the body. Page 3 Sheriff?Coroner Alameda County Body of PAUL WILBERT LEE There is some focal scarring. white in color, along the edge of the right ear ranging upwards to l_inch in greatest dimension. Two areas appear to be present. The hair is black and 1/2 inch long. Pupils are round. Irides are brown. Arcus senilis is present. Sclerae may be mildly icteric. No petechial hemorrhages are noted. Ears, nose and lips are otherwise nonremarkable. Mustache and beard are present. The neck is nonremarkable. The chest is flat. Breasts are consistent with an adult male.? The abdomen is distended. There is swelling of the external genitalia. There is some probable skeletal muscle atrophy of both legs, including the thighs and lower legs. There is mild edema of both arms and hands. The arms and hands are without ?urther abnormalities. The back is nonremarkable- INTERNAL EXAMINATION The body is opened through the usual INCISION. No abnormalities. BODY CAVITIES: The PEG tube is properly placed and without abnormalities. The body cavities are lined by smooth, glistening surfaces. Ribs and diaphragms are intact. No old Page 4 Sheriff?Coroner Alameda County Body of PAUL WILBERT LEE rib fractures are identified. No fluid is present. In situ, the heart is enlarged, with the apex beyond the left midclavicular line. The heart weighs 500 grams. The epicardial surface is smooth. Ventricular myocardium is brown. No acute or old myocardial infarctions are identified. There is mild four-chamber dilatation of the heart. Valves are normal. Coronary ostia are patent. There is a stent in the proximal end of the left anterior descending coronary artery that appears to be nonremarkable. The proximal end of the left circumflex coronary artery appears to be calcified making examination difficult. The possibility of an underlying stent - cannot be excluded. The right coronary artery appears small. No thrombi are present. VESSELS: The aorta and tributaries are mildly to moderately involved with atheromatous change. The pulmonary artery and venous system contain no thromboemboli. TRACHEA AND BRONCHI: Lined by pale yellow mucosal surfaces. LUNGS: The left lung weighs 1000 grams. The right lung weighs 1100 grams. Pleural surfaces are smooth. Lung is prominently congested and edematous. Lung has a uniform firmness to them. No actual areas of Alameda County Body of PAUL WILBERT LEE Page 5 Sheriff~Coroner bronchopneumonia are identified. Airways contain yellow sputum. The arterial system is nonremarkable; ORAL CAVITY: The_teeth are natural, with many teeth chronically missing. None are acutely missing or loose. The tongue is normal. ESOPHAGUS: Lined by'a mhite, wrinkled mucosal surface. STOMACH: Contains 50 cc of green mucoid material. The mucosal surface is tan. No tumors or ulcers are noted. Covered by smooth serosal surfaces. No abnormalities are noted. LIVER: Weighs 2200 grams. The serosal surface is smooth. The anteriOr margin is sharp. The is mildly involved With fatty metamorphosis. GALLBLADDER: The gallbladder is of normal size. Its surface is smooth. Its wall is of normal thickness. It is lined by a green velvety mucosal surface. It contains 10 cc of bile and no stones. RANCREAS: The pancreas is of normal size. Its is yellow~brown and lobulated. No tumors are present. No saponification is noted. SPLEEN: The spleen weighs 150 grams. Its capsule is gray and smooth. Its is red?purple and soft. 100 101 102 103 104 105 106 107 108 109 110 Page 6 Sheriff?Coroner Alameda County . Body of PAUL WILBERT LEE ADRENAL GLANDS: The adrenals are normal in size and have their usual triangular shape. Sectioning of them reveals non? remarkable cortex and medullary parts. No hemorrhages are present. KIDNEYS: The kidneys weigh 160 grams each. Surfaces are smooth.? is brown and moderately congested. There is a distinct corticomedullary separation. Papillae are normal. The calyces and pelves of both kidneys are nonremarkable. No obvious abnormalities are noted of the ureters. No stones are present. BLADDER: The bladder contains no urine. It is lined by a etan mucosal surface. No trabeculation or tumors are present. No diverticula are noted. PROSTATE: The prostate is of normal size. Its is yellow?white and rubbery. No tumors are noted. TESTICLES: atrophied; MUSCULOSKELETAL SYSTEM: No abnormalities noted. NECK: The hyoid bone and laryngeal structures are intact. Soft tissue about the larynx is normal. The larynx is free of obstructing material. The cervical vertebral column is non- remarkable. The thyroid gland is of normal size. Sectioning of it reveals a nonremarkable red-brown 111 112 113 114 115 116 117 ?118 119 120 121 122 123 124 125 126 127 128 129 130 131 Sheriff?Coroner Page 7 Alameda County Body of PAUL WILBERT LEE CENTRAL NERVOUS SYSTEM: Soft tissue about the cranial vault is normal. The brain weighs 1250 grams. There is mild flattening of the gyri and sulci of the cerebral hemispheres. Sectioning of the brain reveals a uniform, slight softness_to brain Otherwise, no abnormalities are noted. No old cerebral oontusions are noted. No xanthoohromic discoloration of the subaraohnoid membranes is identified. No organized subdural hemorrhage is preSent. Stripping the dura from the inner table of the skull reveals no abnormalities. SPECIMENS: l) Heart?s blood 2) Leg blood 3) Liver 4) Tissue 5) Photographs Thomas Wayne Rogeds, M.D. TWR/jkm