Anna Nicole Smith's Death Ruled Accidental Overdose

By David Montgomery
Washington Post Staff Writer
Tuesday, March 27, 2007

Former Playboy Playmate Anna Nicole Smith died of an accidental overdose of a rarely prescribed sleeping drug that interacted fatally with several other prescription medications, a medical examiner in Florida announced yesterday.

A pharmacopeia of at least nine drugs was in her body -- from methadone and valium to flu medicine and injectable vitamins -- but it was the sleeping medication chloral hydrate, in combination with four other sedatives, that killed her, said Broward County Medical Examiner Joshua Perper.

Perper and police investigators ruled out homicide and suicide even though toxicology tests showed she took more of the sleeping medication than is recommended, along with normal dosage levels of the other drugs. Once more popular than it is now, chloral hydrate has been surpassed by other remedies. But Smith, 39, preferred it, Perper said in a telephone interview. "She tried other sleeping drugs, and they didn't work as well for her, and she liked this one," he said.

The finding of accidental death was based on a series of investigators' deductions from the evidence, including autopsy results, interviews with friends about her state of mind, and information such as e-mails recovered from her laptop and that of her companion, Howard K. Stern.

People who want to kill themselves usually take large amounts of drugs, Perper said. The amount of the sleeping drug in Smith's body was not necessarily lethal by itself. "In this case, there was still a lot of chloral hydrate left in the bottle," and all the other drugs in her body were at "therapeutic" levels, Perper said.

As for homicide, chloral hydrate has an awful taste. "You cannot disguise it or slip it into a drink," Perper said, and there were no signs on her body of "forced feeding."

"We are convinced, based on an extensive review of the evidence, that this case is an accidental overdose with no other criminal element present," said Charlie Tiger, chief of the Seminole tribal police department, who, with Perper, addressed reporters earlier in the day outside the medical examiner's office in Dania Beach, Fla. Smith was pronounced dead Feb. 8 after being taken by ambulance from her suite at the Seminole Hard Rock Hotel and Casino, on tribal property.

Despite the many factual pieces investigators added to the puzzle -- an exhaustive tick-tock of her last days and the substances she ingested -- the ultimate reading of Smith's intentions was a judgment call.

"It's one of those things, 'Who knows?' " said Wendy Klein-Schwartz, pharmacist with the Maryland Poison Center at the University of Maryland, Baltimore, who looked at the drug results posted online by the medical examiner's office. "She did have an awful lot of chloral hydrate on board. . . . She might have intentionally taken more than a therapeutic amount of chloral hydrate, but not to kill herself. That would be accidental."

Perper told reporters, "We believed the indications of suicide were not strong enough to balance against indications of accident."

Perper said he does not know who -- including perhaps Smith herself -- gave her two tablespoons full of the sleeping drug on Feb. 5, and more doses Feb. 6 and Feb. 7. He said it was not his job to cast blame on any medical professionals who may have prescribed the many drugs she took and who could have warned her about drug interactions.

"The medical examiner is not getting involved in questions of the quality of medical care," he said in the interview. "Our role is to make a determination of the cause and manner of death. . . . The quality of medical care is not my function, unless the negligence is so obvious that it actually caused the death."

Knowing he had a high-profile case on his hands, Perper said he went to great lengths to rule out every possibility. His team even used a Geiger counter to check for radiation poisoning.

Investigators offered this reconstruction of Smith's last days:

Even though she had suffered bouts of depression and drug abuse in the past, and had been treated for depression again after the death of her son, Daniel, and the birth of a daughter in the fall, she was in good sprits in the Bahamas before flying to Florida. She was taking methadone for pain, and growth hormone, possibly for weight reduction. She received an injection in her left buttock of either growth hormone, vitamin B12 or immunoglobulin.

Arriving at the hotel Feb. 5, she had a fever of 105. She also had complained of pain in her buttock. She was given Tamiflu, antibiotics and placed in an ice bath. Her fever dropped. She took sleeping medicine and went to bed.

Over the next few days she took various sedatives, drank fluids, watched television, took more sleeping medicine. The morning of Feb. 8, Smith was awake with no complaints except great fatigue. She went back to bed and was found unresponsive early that afternoon.

"When many drugs act together, they may often have unpredictable and dangerous effects," Perper said. He listed "abscesses of buttocks," intestinal infection and possible flu as contributory causes of her death.

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