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Freddie Gray autopsy: excerpt from the report

The Baltimore Sun
Read an excerpt from the Freddie Gray autopsy report.

The following is an excerpt from Freddie Gray's autopsy report, which was obtained by The Baltimore Sun:

OPINION:

This 25 year old, African American male, Freddie Carlos Gray Jr., died of a Neck Injury sustained as an unbelted occupant of a police transport van. The cause and manner of death are based on autopsy findings, review of medical records and the investigation of the circumstances surrounding the death, including available witness statements, captured scene videos and examination of the police transport vehicle. By report, the deceased was taken into custody following a police bike and foot pursuit on 4/12/2015. Upon being apprehended, Mr. Gray placed himself on the ground and his hands were cuffed behind his back. He reportedly asked for an inhaler, but none was found on his person. He was assisted to the police van on Presbury Street (1st stop), exhibiting both verbal and some physical resistance. Mr. Gray is seen on video entering the right hand compartment of the van, bearing weight on his legs and actively speaking. He was reportedly placed on the metal bench running from front to back along the outside wall of the van (the bench measures approximately 13" wide and 8' long allowing for 19" between the metal wall dividing the van into two discrete compartments and the bench edge). After the inner and outer doors were closed, it is reported that Mr. Gray could be heard yelling and banging, causing the van to rock. Originally the destination of the van was Central Booking; however, several intervening stops were made before it was finally diverted to the Western District headquarters. The 2nd stop was several blocks down (on Baker Street) to place an identification band and leg restraints on Mr. Gray. Reportedly, Mr. Gray was still yelling and shaking the van. He was removed from the van and placed on the ground in a kneeling position, facing the van doors, while ankle cuffs were placed, and then slid onto the floor of the van, belly down and head first, reportedly still verbally and physically active. The 3rd stop was captured on video at Mosher Street and North Fremont Avenue, where the van driver stopped the van, got out and looked in the back of the van. The van proceeded to the 4th stop (at Dolphin Street and Druid Hill Avenue) where the van driver called for assistance to check on Mr. Gray. The assisting officer opened the doors and observed Mr. Gray lying belly down on the floor with his head facing the cabin compartment, and reportedly he was asking for help, saying he couldn't breathe, couldn't get up and needed a medic. The officer assisted Mr. Gray to the bench and the van continued on its way until it was diverted to pick up another individual who was in custody. At this 5th stop (at North Avenue and Pennsylvania Avenue), Mr. Gray was found kneeling on the floor, facing the front of the van and slumped over to his right against the bench, and reportedly appeared lethargic with minimal responses to direct questions. The second individual was placed in the left hand compartment of the van and the vehicle was driven to the Western District headquarters. By report, this second detainee said that he heard Mr. Gray banging and kicking through the metal divider. On arrival, Mr. Gray was found in a kneeling position, unresponsive and not breathing. Emergency medical services were activated and he was transported to University Medical Center with active resuscitation.

At the hospital resuscitation attempts were successful with the return of spontaneous circulation. Mr. Gray exhibited dilated pupils and showed no motor response to stimuli. No obvious external injuries, except for an abrasion (skin scape) on the top of the left shoulder were identified on initial examination. Admission toxicological testing was positive for the presence of opiates and cannabinoid in the urine. A computed tomography scan (CT) of the head and neck was negative for intracranial bleeding or fractures of the facial bones or skull, but demonstrated an unstable C4/C5 fracture/dislocation with high grade spinal canal compromise as well as a left vertebral artery injury. A magnetic resonance imaging (MRI) study, performed revealed a tiny left interventricular hemorrhage, near transection of the spinal cord, rupture of multiple stabilizing ligaments at the level of C4/C5, extensive edema of soft tissues of the posterior neck region and a small fluid collection anterior to C3 through C7; no other abnormalities of the uninjured cervical vertebral column, spinal cord or adjacent soft tissues were described in the report. Mr. Gray was stabilized and closed reduction of the vertebral dislocation was attempted without success. He was taken to the operating room on 4/14/2015 for C3-C6 laminectomy and fusion of C4 and C5. The operative note made no mention of healed or healing scars on the neck or evidence of previous injury or surgical interventions. Mr. Gray remained in a comatose state with continual electroencephalogram monitoring that indicated diffuse cerebral dysfunction. Follow up CT and MRI scans showed extension of the spinal cord edema into the brainstem and into the distal cervical spinal cord. On 4/19/2015 as Mr. Gray was being positioned he had an episode of severe hypertension and tachycardia followed by hypotension and bradycardia and eventually, pulseless electrical activity. Despite resuscitative efforts, Mr. Gray was pronounced on 4/19/2015.

At autopsy, the external examination was significant for generalized edema and evidence of medical therapy. A healing, patterned abraded laceration (scraped skin tear) was on the right temple, a healing abrasion on the left temple, small healing abrasions on the left cheekbone, and healing linear abrasions on the wrists and right ankle. Reflection of the scalp revealed a subscalp hematoma on the lateral aspect of the left side of the back of the head just superior to the neck region, and focal scalp hemorrhage under the abraded laceration on the right temple. Reflection of extensive areas of skin of the torso and the upper and lower extremities identified areas of hemorrhage on the lateral aspects of the wrists and ankles, consistent with placement of wrist and ankle restraints. Faint areas of subcutaneous hemorrhage were over the left scapular and right postero-inferior costal margin. No deep muscle hemorrhage of the torso or extremities or fractures of the long bones of the extremities were identified. * No injuries that would suggest the use of a neck hold, Taser deployment or physical restraint, other than wrist and ankle cuffs, were identified. Examination of the brain showed edema and other secondary changes due to interruption in oxygen/blood flow, which were more prominent in the parietal and occipital lobes and the medulla of the brainstem. The spinal cord was intact, but showed extensive edema, traumatic contusion (bruising) and necrosis of the cervical spinal cord, extension of the necrosis into the lower brainstem and high thoracic regions, and secondary, non-traumatic changes due to probable re-perfusion injury of the entire spinal cord. The internal examination showed no evidence of injury to the ribs, thoracic or lumbar vertebral column, pelvic bones or the internal organs. An anterior neck dissection showed an intact hyoid bone and laryngeal cartilage.

Review of the chronology of the events from the when Mr. Gray was taken into custody in the context of a severe and unstable cervical spine fracture/dislocation that would be immediately symptomatic, is most consistent with Mr. Gray sustaining the injury in the police van sometime after the 2nd stop where ankle restraints were placed and before the 4th stop when the driver called assistance. At this 4th stop, Mr. Gray was displaying symptoms of a high spinal cord injury: difficulties in breathing and movement. The type of fracture/dislocation documented in imaging studies on admission is a high energy injury most often caused by abrupt deceleration of a rotated head on a hyperflexed neck, such as seen in shallow water diving incidents. While it cannot be excluded that this injury could occur while lying on the floor and sliding back and forth with the movement of the van, the likelihood of sufficient acceleration/deceleration to generate the energy needed is less likely in this position. Further, the most significant impact to the head and the impact consistent with the neck injury is on the left lower back area of the head, is not consistent with injury

in this prone position. Although Mr. Gray was placed belly down on the floor of the van at the 2nd stop, he would have been able to get to his feet using the bench side and the opposite wall. As the clearance between the interior floor and roof was approximately 4 feet (Mr. Gray measured 5'9" in length), he would have been hunched over with his neck in a flexed position if he had risen off the floor. Mr. Gray was restrained with his wrists behind his back and at the ankles, was not belted with the safety belts that were present in the van, and due to an obstructed view of the roadway would have had trouble anticipating the van's motion; therefore, he was at risk for an unsupported fall during acceleration or deceleration of the van. An unexpected turning motion, acceleration or deceleration of the van would have precipitated him into the side walls, the door or the front of the van depending on his position, resulting in the left posterior impact to his head with injury to the spinal cord in his flexed neck. If the motion/acceleration/deceleration of the van was abrupt enough, given the confined space in the vehicle, it is possible that his neck injury occurred with him in a partially reclining position or as he was changing his position on the floor of the van. As the fracture/dislocation was considered very unstable, it is unclear whether the spinal cord lesion was complete, as documented in admission imaging studies, or in the spectrum of spinal concussion or contusion at the time of the fracture/dislocation in the van with evolution of the spinal cord injury during the movement of Mr. Gray to the bench, the subsequent stops and the motion of the van. Injury at this level of the spinal cord would have caused loss of function of the limbs and have direct effects on the mechanics of respiration through partial to near total paralysis of the diaphragm, the full function of which depends on the nerves associated with the part of the spinal cord that was damaged. Therefore, the time the injury most likely occurred was after the 2nd but before the 4th stop of the van, and possibly before the 3rd stop when a video showed the driver stopping, getting out, and looking in the back of the van. The reported kicking heard after the 4th stop would not have been possible; however, a seizure resulting from decreased oxygen supply to the brain may have caused the banging noise reportedly heard from Mr. Gray's compartment.

Based on the sequence of events and the described progressive alteration of mental and physical status, Mr. Gray's neck injury occurred while in custody, in and during transport in the police van. Safety equipment was available but not used. Therefore, it was not an unforeseen event (a medico-legal definition of an accident) that a vulnerable individual was injured during operation of the vehicle, and that without prompt medical attention, the injury would prove fatal. Due to the failure of following established safety procedures through acts of omission, the manner of death is best certified as Homicide. Prolonged hospitalization precluded relevant postmortem toxicological testing. 

[Signed]
Carol H. Allan, M.D.
Assistant Medical Examiner

[Signed]
David R. Fowler, M.D.
Chief Medical Examiner

Date signed: 4/30/2015

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