North Carolina Department of Health and Human Services Office of the Chief Medical ene NC OCME| 3025 Mail Service Center Raleigh, NC 27699-3025 C OCN Telephone 919-743-9000 Fax 919-743-9099 REPORT OF AUTOPSY EXAMINATION DECEDENT Document Identifier B202207504 Autopsy Type — ME Autopsy Name William Surles Age 64 yrs Race _ Black Sex M AUTHORIZATION Authorized By Savannah Martin EMT-P Received From Harnett ENVIRONMENT Date of Exam — 12/21/2022 Time of Exam 09:30 Autopsy Facility Office of the Chief Medical Examiner Persons Present —_ Ms. Lisa Allison- Moon (Autopsy Technician); W. Del Carmen, North Carolina State Bureau of Investigation CERTIFICATION Cause of Death PHYSICAL ASSAULT INCLUDING BLUNT FORCE TRAUMA OF HEAD Contributory: HYPERTENSIVE AND ATHEROSCLEROTIC CARDIOVASCULAR DISEASE The facts stated herein are correct to the best of my knowledge and belief. Digitally signed by Janet Baranello MD. 29 September 2023 08:53, DIAGNOSES I. Blunt force injuries of head. A. Laceration of right lateral brow. B. Contusion of left eye and cheek. C. Few lacerations, abrasions, and contusions of left labial mucosa. D. Scattered foci of deep scalp and periosteal hemorrhage, frontotemporal and parietal scalp. E. Intramuscular hemorrhage, temporalis muscles Il, Hypertensive and atherosclerotic cardiovascular disease. A. Cardiomegaly (heart 560 grams). B. Coronary artery atherosclerosis, severe. C. Aortic atherosclerosis, moderate. D. Arterionephrosclerosis, moderate. E. Circle of Willis atherosclerosis, mild. F. Remote lacunar infarct, right basal ganglia. III. Pulmonary emphysema, moderate. IV. Pulmonary aspergilloma, non-invasive. A. Pleural effusions (1150 mL. right pleural cavity; 500 mL. left pleural cavity). B. Pericardial effusion (100 mL). V. Postmortem nasopharyngeal swab: negative for COVID-19 and influenza viruses. VI. Toxicology. Page 1 of 7 202215961 29 September 2023 08:53A. Negative for common medications, common drugs of abuse, or ethanol (alcohol). IDENTIFICATION Body Identified By Papers/ID Tag EXTERNAL DESCRIPTION Length 71 inches Weight _ 193 pounds Body Condition —_ Intact The body is received in a zipped body bag sealed with tamper-evident plastic locks #0050190 and #0002763. The locks are retained in the save jar. An attached tag bears the decedent's name. In addition, identification tags bearing the decedent's name are on the left wrist. CLOTHING AND PERSONAL EFFECTS: The body is received clad in an orange prison-issued shirt, orange prison-issued pants, one black shoe (left foot), one yellow medical sock (left foot), and one black medical boot (right foot). There are no accompanying personal effects. The body is also clad in an adult diaper which is soiled with urine and feces which is discarded. EVIDENCE OF MEDICAL THERAPY: Electrocardiogram pads are affixed to the upper chest and lower quadrants of the abdomen. Gauze and an elastic wrap bandage are secured around the right foot. The right foot 1st digit has been previously partially amputated and has a well-healed stump margin; the right foot 2nd digit has been recently amputated with a healing, previously sutured stump margin; no hemorrhage or signs of infection are seen. The body is that of a normally developed, well-nourished, dark-complexioned male appearing consistent with the listed age. The body is cold, well-preserved, and has not been embalmed. Rigidity is moderate in the jaw and extremities. Lividity is red-purple, fixed, and in a posterior distribution, The brown-gray, curly scalp hair measures up to 1/2" with male-patterned baldness. Facial hair on the chin, cheeks, and upper lip measures up to 1/2". The irides appear brown, the corneas clear, and the sclerae white with Tache noire. The left eye has hemorrhage as described below. The ears are normally formed and without drainage. The nose is intact, and the nares unobstructed. The lips are normally formed. The teeth are natural and in fair condition. The superior and inferior frenula are intact. Oral mucosal injuries are seen as described below. The neck is symmetrical and without evidence of injury. The chest is normally formed, symmetrical, and without palpable masses. The abdomen is flat, soft, and without palpable masses. The external genitalia are those of an adult male with testes palpable within the scrotum. The back is straight and symmetrical. The anus is atraumatic. The arms are normally formed. No needle punctures, track marks, or ventral wrist scars are seen. The fingernails are dirty and with overhangs up to 1/4", The legs are normally formed and without edema or deformities; the right foot has amputation as previously described. The toenails are yellow, focally thickened, and with overhangs up to 1/2". BODY MARKINGS: Scattered on the lateral and upper back and flanks are round to irregular and vaguely linear, hyperpigmented scars, focally with overlying superficial erosion measuring up to 4" in greatest dimension. On the left posterior lower leg is a 5 x 4", irregular, hypopigmented scar with peripheral hyperpigmentation. Scattered on the anterior knees and anterior lower legs as well as the buttocks and posterior legs are hyperpigmented, round to vaguely linear scars, measuring up to 2" in greatest dimension. On the right lateral ankle is a 5", curvilinear, vertically oriented, hypopigmented scar. Page 2 of 7 202215961 29 September 2023 08:53INJURIES BLUNT FORCE INJURIES OF HEAD Slightly inferior and lateral to the right brow is a 5/8", linear, horizontally oriented, laceration with tissue bridging and without undermining. The skin surrounding this area is somewhat edematous without definitive contusion/hematoma. Surrounding the left eye and extending onto the left cheek is a4 1/2 x 3 1/2" area of irregular, faint, red-purple to blue-purple contusion. Underlying this area the left bulbar and palpebral conjunctivae have punctate and confluent areas of hemorrhage, measuring up to 1/2" in greatest dimension. The left upper and lower labial mucosa have multiple irregular partial-thickness and superficial lacerations with surrounding red-purple contusions and superficial abrasions, vaguely aligning with the teeth, and measuring up to 3/4" in greatest dimension. Internally, the scalp has multiple foci of deep scalp and periosteal hemorrhage, predominantly on the frontal, parietal, and temporal scalp, measuring up to 4 cm in greatest dimension; focal areas of intramuscular hemorrhage are also seen in the temporalis muscles underlying scalp hemorrhage. DISPOSITION OF PERSONAL EFFECTS AND EVIDENCE The following items are released with the body None. The following items are preserved as evidence Pulled scalp hair; blood spot card; all clothing. All items are released to W. Del Carmen, North Carolina State Bureau of Investigation, on 12/21/2022. PROCEDURES Radiographs A postmortem radiograph is taken. Microbiology ‘A postmortem nasopharyngeal swab is submitted to the North Carolina State Laboratory of Public Health and is negative for COVID-19 and influenza viruses. INTERNAL EXAMINATION Body Cavities The abdominal fat layer measures up to 4 cm in thickness. The pleural and pericardial cavity contain serosanguinous effusions (right pleural cavity 1150 mL; left pleural cavity 500 mL; pericardial cavity 100 mL). The peritoneal cavity contains no hemorrhage or excess fluid. The serosal surfaces are smooth, glistening, and without adhesions. The organs are normally located. The diaphragm is intact. The body cavities have no internal injuries. Cardiovascular System Heart Weight 560 grams The heart has a conical shape with a smooth, glistening epicardium, The coronary arteries have a normal origin and distribution with right dominance. The left anterior descending, left circumflex, and right coronary arteries have greater than 90%, greater than 90%, and 75% stenosis by yellow, focally- calcified atherosclerotic plaque, respectively. The myocardium is red-brown, firm, and uniform without focal fibrosis, softening, or hyperemia. The ventricles are not dilated or hypertrophied. The thicknesses of the posterior right ventricle, posterior left ventricle, and interventricular septum are 0.3, 1.0, and 1.3 cm, respectively. The endocardium is intact, smooth, and glistening. The cardiac valve leaflets are of normal number, pliable, intact, and free of vegetations. The atrial and ventricular septa are free of defects. The aorta follows its usual course and has moderate atherosclerosis with few ulcerative plaques. No Page 3 of 7 202215961 29 September 2023 08:53vascular anomalies or aneurysms are identified. The venae cavae and pulmonary arteries are without thrombus or embolus. The pulmonary arteries have mild atherosclerosis. Respiratory System Right Lung Weight _ 540 grams Left Lung Weight 500 grams The tongue, strap muscles, and other anterior neck soft tissues have no hemorrhage. The hyoid bone and the cartilaginous structures of the larynx and trachea are normally formed and without fracture. The cervical vertebrae have no displacement, hypermobility, or crepitus. There is no prevertebral soft tissue hemorrhage. The lungs have the usual lobation. The pleurae are smooth and glistening; the lungs have a marked amount of anthracotic pigment. The lungs are well-expanded and crepitant with focal blebbing. The parenchyma is dark red and exudes a minimal amount of fluid. The lungs have no consolidation, hemorrhage, infarct, tumor, or gross fibrosis. The airways are unobstructed, lined by smooth, pink-tan mucosa, and contain no foreign materials. Gastrointestinal System The esophagus and gastroesophageal junction are unremarkable. The stomach contains approximately 30 mL of tan, partially masticated food without visible pills or pill residue. The gastric and duodenal mucosae are intact and unremarkable. The small and large intestines and appendix are unremarkable to inspection and palpation. Liver Liver Weight — 1840 grams The capsule has fine fibrosis with vague micronodules. The parenchyma is red-brown to somewhat yellow and firm with vague fibrosis and micronodules without frank cirrhosis, mass, or hemorrhage. The gallbladder contains a small amount of bile and no stones. Its mucosa is uniform, and the wall is not thickened. Spleen Spleen Weight 260 grams The capsule has mild thickening without hyalinosis. The parenchyma is maroon, firm, and uniform. Pancreas The pancreas has a normal size, shape, and lobulated structure. The parenchyma is pink-tan, firm, and uniform. Urinary Right Kidney Weight 200 grams Left Kidney Weight — 250 grams The Kidneys have a normal shape and position. The cortical surfaces are granular and retracted with broad-based scars and large areas of pitting. The corticomedullary junctions are irregular with dilatation of the pelves and green-tan, somewhat waxy debris within the collecting system, but without purulence or frank kidney stones. The renal hilar fat is also somewhat fibrotic. The urinary bladder contains approximately 10 mL of cloudy yellow urine. The mucosa is intact, and the bladder wall is not hypertrophied. Reproductive The prostate gland is of average size and grossly unremarkable. Endocrine The thyroid gland is not enlarged, and the lobes are symmetrical. The parenchyma is uniform, firm, and red-brown. The adrenal glands have a poorly defined corticomedullary junction with probable cortical atrophy, and the left adrenal gland has a 0.5 cm well-circumscribed tan-yellow nodule consistent with an adrenal cortical adenoma. The pituitary gland is not enlarged. Neurologic Brain Weight 1510 grams Page 4 of 7 202215961 29 September 2023 08:53The scalp has hemorrhage as previously described. The calvarium and base of the skull are normally configured and have no fractures. The dura is intact, and there is no epidural or subdural-hemorrhage. NC OCME The leptomeninges are glistening and transparent without underlying hemorrhage, exudate, or'cortical contusions. The hemispheres are symmetrical and have a normal gyral pattern. There is no flattening of the gyri, narrowing of the sulci, midline shift, or evidence of herniation. The arteries at the base of the brain have mild atherosclerotic changes without aneurysms. Sections through the cerebral hemispheres have a uniform, intact cortical ribbon and uniform white matter. The right basal ganglia has a 0.7 cm area of yellow-brown lacunar infarct. Otherwise, the thalami, hippocampi, and other internal structures are symmetrical and without focal change. The ventricles are not enlarged, and the linings are smooth and glistening. Sections of the brainstem and cerebellum show an intact structure without focal lesions. Immunologic System There is no enlargement of the lymph nodes of the neck, chest, or abdomen. The thymus is involuted. Musculoskeletal System The musculoskeletal system is well-developed and free of deformity. There are no fractures of the clavicles, sternum, ribs, vertebrae, or pelvis. The ribs are not brittle. The skeletal muscle is dark red and firm. MICROSCOPIC EXAMINATION Microscopic Comment SLIDE KEY: Al: Heart (left ventricle), coronary artery x2 A2: Lungs A3: Liver, right kidney The lung lesion seen is consistent with a non-invasive aspergilloma. No special stains or confirmatory cultures were performed. No evidence of disseminated disease is seen. Cardiovascular One section of left ventricular myocardium shows perivascular and interstitial fibrosis, focally in broad swaths with active fibrosis with fibroblast proliferation and with scattered hemosiderin-laden macrophages. Few foci of contraction band necrosis are seen without associated inflammation, predominantly in a subepicardial distribution. Representative sections of coronary artery show focally calcified and chronically inflamed, severe atheromatous stenosis with intimal thickening, medial hypertrophy, and prominent cholesterol clefts. Focal acute plaque hemorrhage is seen without thrombus formation. Respiratory One section each of the upper lobe of the right lung and lower lobe of the left lung show diffuse alveolar expansions with loss of the alveolar walls and alveolar septal clubbing. Alveolar spaces contain collections of pigmented macrophages. The right lung shows a minute lesion consisting of a ball of septate, acute angle branching fungal hyphae with a surrounding fibrous capsule and associated foreign body giant cells and a rim of chronic inflammation. No evidence of angioinvasion is seen. Examination under polarized light shows scattered needle-shaped refractile crystalline material in areas of anthracosis. Liver One section of liver shows sinusoidal congestion in a centrilobular distribution and minimal macrovesicular steatosis (5% of parenchyma). There is mild expansion of portal tracts by lymphoplasmacytic inflammation and possible early bridging fibrosis. No lobular inflammation or hepatocyte necrosis are seen. Genitourinary Page 5 of 7 202215961 29 September 2023 08:53One section of the right kidney shows scattered globally sclerotic glomeruli (15%) without inflammation. There are scattered glomeruli with mesangial thickening and few = glomerulosclerosis (Kimmelstiel-Wilson lesions). The arterioles show hyalinosis, aitd thefe)is mijldl= peritubular and periglomerular fibrosis. The tubules show no definitive subnuclear vacuolization™"" (Armanni-Ebstein lesions) and are otherwise unremarkable except for autolysis. The interstitium is moderately expanded by fibrosis, and the vessels show moderate wall thickening. Examination under polarized light shows no accumulation of crystalline material. SUMMARY AND INTERPRETATION According to information received from Harnett County Medical Examiner, North Carolina State Bureau of Investigation, and medical records, this 64-year-old man was found unresponsive in bed in his jail cell shared with one other cellmate on the morning of 12/19/2022 after last being known alive the evening prior. He had apparent blunt force injuries of the head and blood was reportedly spattered around the jail cell. 911 was called and Emergency Medical Services arrived on scene where death was pronounced without resuscitative efforts on 12/19/2022 at 0838. No video footage from within the cell is available; however, law enforcement had suspicions for foul play due to statements made eluding to the decedent's death being non-natural as well as the blood spatter on scene. Review of available medical records documented a history of asthma, hypertension, insulin-dependent diabetes, and a recent hospital admission on 12/06/2022 for osteomyelitis of the right foot in the setting of diabetes requiring amputation of the right 2nd toe and antibiotics. He was discharged back to the jail in stable condition on 12/12/2022. The autopsy documented a well-developed, well-nourished adult male with blunt force injuries of the head including lacerations of the right eyebrow and left labial mucosa, abrasions and contusions of the left labial mucosa, and a contusion of the left eye and left cheek. There were a few, scattered deep scalp hemorrhages and bilateral temporalis muscle hemorrhages involving multiple regions of the scalp. No craniofacial bone or intracranial injuries were seen. No other injuries were seen involving the torso or extremities. The blunt force injuries of head were multiplanar such that the injuries were not consistent with a single blunt impact; there were a minimum of five blunt impact sites (right face, left face, right temporal/parietal head, left temporal head, occipital head). Natural disease identified at autopsy included hypertensive and atherosclerotic cardiovascular disease including cardiomegaly (heart 560 grams), severe coronary artery atherosclerosis, moderate aortic atherosclerosis, moderate arterionephrosclerosis, mild circle of Willis atherosclerosis, and a remote infarction of the right basal ganglia. There was moderate pulmonary emphysema, bilateral pleural effusions, and a pericardial effusion; a postmortem nasopharyngeal swab for COVID-19 and influenza viruses was negative. A minute, microscopic pulmonary aspergilloma was seen, which appeared non- angioinvasive. Toxicological analysis on postmortem blood detected no common medications, common drugs of abuse, or ethanol (alcohol) Follow up with law enforcement revealed ongoing concerns for foul play. ‘The blunt force injuries of the head were distributed such that a single blunt impact (i.e., fall) would not be sufficient to explain the injuries. Additionally, while no findings suggestive of asphyxia were seen, the role of other external factors such as asphyxia (i., external neck/torso compression, smothering) cannot be fully excluded based on autopsy findings alone. As such, based on the autopsy findings and circumstances surrounding the death, as currently understood, it is my opinion that the cause of death is physical assault including blunt force trauma of head. Hypertensive and atherosclerotic cardiovascular disease is contributory to death. The manner of death is classified as homicide. DIAGRAMS 1, Adult MALE autopsy diagram Page 6 of 7 202215961 29 September 2023 08:53NC OCMI State of North Caroina (Office of the Chief Medical Examiner B_22- 4504 Raleigh, North Caroina Examined by_)B Date:_12(3 | ADULT MALE AUTOPSY DIAGRAM IDENTIFICATION: _—1D checked A 0050140 #0009964 Page 7 of 7 202215961 29 September 2023 08:53,