Top medical examiner doubts Army veteran's death in Brevard jail was an accident
A top-ranking Florida medical examiner has called into question the findings of the autopsy of Gregory Lloyd Edwards, a 38-year-old combat veteran suffering from post-traumatic stress disorder, who died last year after a fight with corrections deputies at the Brevard County Jail.
Dr. Stephen J. Nelson — the chief medical examiner for Florida’s 10th Medical Examiner’s District and the chair of the Florida Department of Law Enforcement’s Medical Examiners Commission — said his review of the autopsy report suggests that Edwards' death was likely a homicide and not an accident as the Brevard medical examiner ruled earlier this year. He also said that the Brevard medical examiner failed to determine what exactly killed Edwards.
Edwards died on Dec. 10, 2018, a day after being rushed to the hospital from the jail where an altercation with a corrections officer during the booking process escalated to involve as many as seven other deputies who beat, pepper-sprayed, tased and cuffed Edwards before securing him in a restraint chair with a spit hood over his head.
Brevard’s medical examiner, Dr. Sajid Qaiser, concluded that Edwards died of "excited delirium and complications" due to "hyperactive and violent state with subsequent restraint." He ruled the manner of death as an accident. Excited delirium is a rare and controversial condition that is often linked to violence involving law enforcement officers.
But Nelson, whose district covers Hardee, Highlands and Polk counties, said he cannot agree with Qaiser's findings.
“The conclusions, to me, from the autopsy are not supported by the autopsy,” said Nelson.
“I'd want to know more about why somebody is calling [a death after] an interaction with law enforcement an accident. When if in fact that same interaction between you and I, I would think they would call homicide,” Nelson said.
"An accident is an unintentional injury. If you're going to wrestle somebody to the ground, pin them to the ground, sit on them, do whatever, I don't think that's an accident."
When a medical examiner determines a death to be a homicide it does not necessarily mean that a crime has been committed. It only means the death was the result of the actions of another. A state attorney or a grand jury determines if the death is a culpable homicide subject to prosecution.
On July 1, State Attorney Phil Archer cleared Brevard deputies involved in Edwards’ death of any criminal wrongdoing under Florida statutes. Archer’s decision is in part based on the findings of the Brevard medical examiner, which have now been thrown into question.
Archer's office did not respond to inquiries about how the manner and cause of Edwards' death was factored into the state attorney's ruling. But in a previous statement to FLORIDA TODAY about the Edwards case, spokesman Todd Brown wrote: "We believe a continued debate offers no greater insight."
FLORIDA TODAY provided Nelson with Qaiser’s autopsy and toxicology reports along with Edwards’ medical records from Rockledge Regional Medical Center, nurses reports from the jail and EMS paperwork, as well as details of the Brevard County Sheriff's Office investigation into Edwards’ death.
Qaiser, the Brevard medical examiner, refused to be interviewed for this story, but in response to Nelson's concerns, communicated via email. His office wrote that "death determinations are based upon the totality of evidence. All of the evidence the ME received led to the determination to the cause and manner of death."
Excited delirium is a medical condition involving psychotic behavior, elevated body temperature, and an extreme fight-or-flight response. It is a collection of symptoms and has many suspected causes, including drug-induced psychosis and paranoid schizophrenia. Alcohol withdrawal and head trauma have also been implicated.
But Nelson said that the only thing he noted in Edwards' toxicology was a therapeutic level of the antihistamine found in Benadryl.
"So I'm not sure what it is that produced his excited delirium,” Nelson said, noting that other factors such as Edwards’ age, weight, fitness and lungs and reported contusions don’t appear compelling enough to draw a conclusion about a definitive cause of death.
“I'm just not clear as to why Mr. Edwards has died, quite honestly, from looking at the autopsy report,” Nelson said.
Nelson said that in cases where excited delirium is diagnosed as the cause of death, all other possibilities must be ruled out and that an examiner's investigation should be exhaustive. But he said Qaiser appears to have failed to examine Edwards thoroughly.
For instance, in a case where somebody died after a fight with seven deputies, he would expect a careful "third spacing" documentation — a medical term to describe the accumulation of blood or other fluids in body cavities outside of blood vessels and soft tissue.
“That's not apparent in the autopsy report," Nelson said. "So, again, I'm not clear as to how Mr. Edwards died.”
He was also puzzled by why there was not a closer and more detailed examination of Mr. Edwards' heart, which Qaiser described in the autopsy as "unremarkable."
"[When] somebody that is met with a death in police custody, we hope at the Medical Examiners Commission that the medical examiner goes above and beyond, with doing a very, very, very, very thorough autopsy, and, in some cases, that includes a lot of what would normally not be typically done for your car crash or your heart attack-type autopsy," Nelson said.
The Medical Examiners Commission is charged by law with establishing standards for the field and reviewing any formal complaints about the work of medical examiners, autopsies included. Most of the members, including the chair, are appointed by the governor. The commission does not have the authority to change an autopsy report, but can discipline medical examiners for negligence in their duties and other violations of state law.
Qaiser has been Brevard's medical examiner since 2006. In 2015, his work was subjected to review by the Medical Examiners Commission which filed an administrative complaint against him and placed him on a one-year probation for not conducting an autopsy of a Korean War veteran who died after he was allegedly overdosed with morphine while in hospice care.
According to the commission's findings. Qaiser overlooked the amount of morphine in the dead man's system and ruled the death an accident. The commission also reviewed 11 other cases under Qaiser and concluded that his work in these cases was also "substandard," and subjected his autopsies during his probation to random reviews.
Nelson said while it is possible that there is a legitimate explanation for Qaiser certifying excited delirium and ruling Edwards' death an accident, it is “not straightforward” from reading the autopsy report that was produced.
“From what I've looked at so far. I wouldn't have certified it as such,” he said.
Nelson said autopsy reports should be clear and self-explanatory. Autopsy reports shouldn't "leave much to the imagination," he added.
“I'm questioning the whole entire label of, of everything here. I'm not clear as to why Mr. Edwards is dead,” Nelson said.
Nelson also expressed confusion as to why Qaiser did not document the presence of sheriff's investigators in the room when the autopsy was performed. That information was obtained by FLORIDA TODAY through a records request that included the sign-in sheet for the autopsy.
"People reading [the autopsy report], don't have to know the ins and outs and the machinations of how the autopsy is performed or the inner workings of the medical examiner's office. It ought to be something that's easily available to everyone. Put it right out there. Tell me who came from the law enforcement agencies. Dictate it. Put it in your autopsy report. Make it easy for everybody who's gonna read this. Tell us who was there," Nelson said.
A review of Qaiser's autopsy of Edwards by the Medical Examiners Commission would take place if probable cause were found after a formal complaint was submitted to the commission.
Alessandro Marazzi Sassoon is a watchdog reporter at FLORIDA TODAY.
Contact him at 321-355-8144, or email@example.com. Twitter: @alemzs