Doctors dispute Delaware student's cause of death
When prosecutors announced charges against three Howard High School of Technology students in the death of Amy Inita Joyner-Francis this week, their decisions were based on an autopsy report showing Joyner died from sudden cardiac death.
The 16-year-old Joyner-Francis was jumped in a girl's bathroom at Howard, and Delaware's medical examiner determined a pre-existing heart condition was triggered by the assault.
Many in the community felt the charges filed were weak. One of the girls was charged with criminally negligent homicide, while the other two were charged with criminal conspiracy.
In the days since, four cardiologists with national reputations say it is highly unlikely for the heart defect to have caused her death.
"Atrial septal defect is not a cause of sudden death," said Dr. Samuel Gidding, chief of cardiology for Nemours/A.I duPont Hospital for Children.
Gidding was adamant that the investigative and media's focus should be on Joyner-Francis's assault, not her heart condition, repeating that he has never heard of any cases of atrial septal defect causing sudden cardiac death.
The Attorney General's Office would not address the doctors' contentions Friday. It stands by the medical examiner's findings and its charging decisions.
"As indicated when charges were filed, the autopsy did not detect any internal injuries or significant blunt force injuries," a statement by the AG's Office reads, "and the medical examiner’s office that actually examined Amy ruled that it was as a result of her cardiac condition."
Joyner-Francis' congenital condition, as determined by the state medical examiner, is a "large" atrial septal defect. Marked by a hole in the wall that separates the top left and right chambers of the heart, the defect typically causes freshly oxygenated blood to mix with deoxygenated blood.
The condition can cause the heart and lungs to work harder than normal.
Dr. Robert H. Beekman, chair of the American College of Cardiology’s Adult Congenital and Pediatric Council, said an atrial septal defect is fairly common – but almost never causes problems in young people.
"It's commonly missed (in routine checkups) and is not one of the congenital defects that leads to sudden cardiac death," Beekman said. "The problems that lead to sudden cardiac death are often problems that cause lethal arrhythmias or heart muscle failure. But [atrial septal defect] doesn't do that in young, healthy people."
From his clinical perspective, even the size of the hole would not make a person more susceptible to sudden cardiac death.
In explaining the charges, the Attorney General's Office said the autopsy showed no "internal injuries or significant blunt force injuries" and said the fatal "cardiac incident would not have occurred if she had not been assaulted."
Beekman said heart defects can complicate a cause of death determination.
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"Oftentimes, medical examiners, when they discover there is a congenital problem, will be willing to attribute the outcome to that problem and it may or may not be the case," he said.
The Cincinnati cardiologist said that to rule a heart defect as a cause of death, a medical examiner should call in an expert in the particular defect. The medical examiner would not answer questions about the investigation so it is not known whether an expert was involved.
A spokeswoman for the Delaware Division of Forensic Science said they would not comment.
“While we appreciate and understand the public interest in this case, the information you are seeking is of a confidential, non-public nature and is the subject of an ongoing criminal prosecution," said Wendy Hudson, chief of communications. "The Division of Forensic Science will not provide any information regarding the Medical Examiner’s findings or comment regarding this case.”
Determining a cause of death uses an examiner’s best medical judgment, said Dr. Keith Rose, assistant professor of medicine with Mount Sinai St. Luke’s in New York City and associate director for the hospital's Center for Advanced Medical Stimulation.
Even with all the information an examiner can receive, it’s not a perfect system and there is a fair bit of medical opinion needed, he added.
“In this case it sounds like he’s ruled everything else out and this was his best guess,” said Rose.
National standards allow medical examiners to gather background information from family and medical providers on an individual as the autopsy report is being completed, explained Dr. David Fowler, Maryland's chief medical examiner and president of the National Association of Medical Examiners.
Fowler said it is not uncommon for medical examiners to call in outside specialists.
He said "it is extremely unfair" to assert that medical examiners jump to conclusions.
Medical examiners work under exactly the same conditions as other physicians, he said, except that they cannot ask the person any questions, take a pulse or perform tests. There are limits to what pathologists can determine, he said.
None of the doctors critical of the cause of death finding had access to the autopsy report, which is not available to the public under Delaware law.
The charges
Investigators determined the April 21 fight was a planned confrontation in the girl's bathroom, but only one girl – Trinity Carr, 16, who was charged with criminally negligent homicide – actually hit Amy, according to the Attorney General's Office.
The fight was filmed, according to court documents, and shows Carr hitting Amy repeatedly in the head and torso with "what appears to be a closed fist."
The video shows Carr leave and Amy try to stand up; then Amy appears disoriented and collapses back onto the floor, the court documents show. When paramedics found Amy, she was unresponsive and shortly after went into cardiac arrest, the report said.
Communication among Carr, Zion Snow and Chakeira Wright – who were each charged with third-degree criminal conspiracy showed – that they planned the assault in the 20 hours prior to the attack, according to court documents. The three girls followed Amy into the bathroom and then began the assault, court papers say.
If convicted, Carr faces a maximum of eight years in prison. Snow and Wright face up to a year.
Attorney John Deckers, who is representing Carr, told the Associated Press the case involves "unique, if not unprecedented," circumstances. He said Carr never imagined the fight would end in anyone's death.
Dr. Jane Crosson, director of pediatric electrophysiology for Johns Hopkins Medicine and associate professor of pediatrics, was also surprised by the cause of death determination.
"I've never heard of such a thing, I'll say that," she said in an email.
Looking at what led to the death
There is room for error when death certificates involve cardiac incidents.
A study authored by Mount Sinai's Rose and published in the Centers for Disease Control and Prevention's journal Preventing Chronic Disease surveyed 521 medical residents and reported that 64.6 percent cited cardiovascular disease as the most frequent diagnosis inaccurately reported, and 46.6 percent had knowingly reported an inaccurate cause of death.
Another study in the American Journal of Medicine found that cardiovascular events are often incorrectly identified as the cause of death.
The study asked 590 medical residents to complete a survey and cause-of-death statement using a sample case of death due to urosepsis, a life-threatening urinary tract infection that spreads to the kidneys.
Forty-five percent of respondents incorrectly identified a cardiovascular event as the primary cause of death.
Dr. Dhanunjaya Lakkireddy lead author of the study, said no matter what the incident, whether from an accident or stab wound, ultimately every patient dies of the heart stopping.
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When filling out death certificates, people often look at only the final terminal event, he said, not specifically what led up to it.
"They state that as the immediate cause of death, which kind of misleads people when they could have died from a lot of other things," he said.
Lakkireddy, professor of medicine and director of the Center for Excellence in AF and Complex Arrhythmias at University of Kansas Medical Center, had a barrage of questions regarding Joyner-Francis's autopsy, specifically whether there was a brain autopsy completed and if the medical examiner's office talked to her family physician to know if she also had a genetic abnormality that would make a person more prone to irregular heartbeats.
The autopsy should be publicly available, he said, especially since criminal charges were influenced by it.
"When you really examine the details of a whole case it opens so many questions that nobody has answers for," Lakkireddy said. "I think this case definitely deserves a deeper dive. I think the ambiguity of arising at the diagnosis with the absence of definite evidence and somehow pinning it to the emotional and physical distress leading to death is really far-fetched."
Jen Rini can be reached at (302) 324-2386 or jrini@delawareonline.com. Follow @JenRini on Twitter.