Episode 13: Two Sides of Codeine

Kohroner Chronicles: A Fatal Dose of Neglect

Not every case that comes across the autopsy table is a sensational act of violence or a calculated crime. Sometimes, it’s not neglect in the traditional sense. Sometimes, it’s ignorance, and the price is tragically high.

In this episode, we look at the death of a 14-year-old girl whose life ended not with malice, but with a misjudgment so severe, it left a trail of questions that needed answers only an autopsy could reveal.

A Special Needs Patient, A Complex Procedure

The young girl in this case lived with profound developmental disabilities. While she was 14 in age, her mental function was closer to that of a 3- or 4-year-old. Her care was a challenge, especially when it came to basic medical procedures, like dental care.

Each year, she was taken to Riley Children’s Hospital in Indianapolis, where dental work could be safely completed under general anesthesia. For such procedures, doctors opted for nasal tracheal intubation, a breathing tube inserted through the nose instead of the mouth, to allow full access to the oral cavity.

A Bleeding Complication

On her most recent visit, the procedure was routine, until the end. Upon removing the breathing tube, she suffered a significant nasal hemorrhage. Not severe enough to panic the physicians, but serious enough to warrant extended monitoring. There was concern she may have aspirated blood into her lungs.

After several hours of observation, she was deemed stable and discharged. Along with instructions, the family was sent home with Tylenol with codeine, a once-common narcotic pain reliever.

A Shocking Morning Discovery

Two days later, on a Wednesday morning, the child’s grandmother found her non-responsive and covered in blood. Emergency services were summoned, but it was too late. She was pronounced dead at the hospital. That’s when I received the call.

What looked like a post-surgical complication now demanded a full forensic autopsy. Had she drowned in her own blood? Had the pain medication played a role?

The Autopsy: Blood in the Lungs

The autopsy confirmed the grim suspicion: her airways were filled with blood. She had aspirated a significant amount, effectively drowning in her sleep. But that wasn’t the end of the mystery.

Toxicology results were ordered, standard in any pediatric death, and especially vital in a case involving prescribed narcotics.

A Toxic Twist

While waiting on lab results, I received repeated calls from the girl’s mother, pressing for the report. She even mentioned needing it for an attorney. Something in the tone raised red flags.

Two weeks later, the toxicology report came in. It revealed toxic levels of codeine in the child’s system. Not a full-blown overdose, but well beyond what would be considered safe or therapeutic.

I immediately contacted the family. When I mentioned the codeine levels, chaos erupted on the other end of the phone. Screaming. An argument in the background. Then silence.

The Math Doesn’t Lie

With the toxicology data in hand, I consulted a clinical pharmacist. Based on the child’s height, weight, and the blood concentration of codeine, she calculated that the girl had received four times the prescribed dose.

When this was communicated to the mother, I also requested that she bring in the medication bottle for further testing.  She had already given it to her attorney, but I insisted that it was still part of an ongoing death investigation, forcing him to return it.  That in turn yielded another twist to the case.

A Quiet Tragedy

There was no indication of intentional harm. But what we had was a deadly combination of miscommunication, misunderstanding, and cover-up after misuse of medication. The codeine had suppressed her cough reflex. Add to that the blood in the airways, and it became a fatal storm.

The final conclusion: a hybrid tragedy, part medical complication, part human error.

Every Body Has a Story

The girl’s life was challenging, and her death was preventable. In Kohroner Chronicles, we often highlight how the smallest oversights can become deadly. This case reminds us that not all forensic mysteries start with a villain. Sometimes, the culprit is a lack of understanding, magnified by high stakes.

Each and every body has a story. And it’s my job to tell it.

Until next time, I’m Dr. Roland Kohr.