Trial Day 7

This court is now in session. You may be seated.

Good morning, Your Honor. May I proceed?

Yes, please.

Your Honor, before the court today, we have the matter of Commonwealth versus Lindsay Clancy. Ms. Clancy is present. She is represented by attorney Kevin Reddington, the Commonwealth is represented by Assistant District Attorney Jennifer Sprague and Assistant District Attorney Shanan Buckingham.

All right. Well, good morning, counsel.

Morning.

Good morning, Ms. Clancy. Morning, Your Honor. All right. Before we bring the jury in, could I speak to counsel just for a couple of minutes?

... court. All rise. [inaudible 00:02:15].

Hear ye, hear ye, hear ye, all persons having anything to do before the Honorable William Sullivan, Justice of the Florida Superior Court, now sitting [inaudible 00:02:56] for the Commonwealth. Your Honor, may I give you attendance and you shall be heard. God save the Commonwealth of Massachusetts. This court is now in session. Please be seated.

Your Honor, may I proceed?

Yes, please.

Your Honor, before the court today, we have the continuation of the jury trial in the matter of Commonwealth versus Lindsay Clancy. Ms. Clancy is present. She is represented by attorney Kevin Reddington. The Commonwealth is represented by Assistant District Attorney Jennifer Sprague and Assistant District Attorney Shannon Buckingham.

All right. Well, good morning again. Nice to see everyone. Thank you for being here. What I'm going to do is I'm going to ask you those questions again and then go over the schedule. Don't forget, you are not sitting this afternoon. Okay? And that's not going to change, so you can count on that. So let me ask you that at this point, has any member of the jury read, seen, heard, or overheard anything from any source about any aspect of this case that would affect your ability to be fair and impartial as a juror?

No.

All right. Next, is there any other serious matter or concern bearing on your service as a juror in this case that anybody needs to bring to my attention?

No.

Great. Thank you again for following those instructions. And what we're going to do is we're going to return to the Commonwealth's case. And like I said, you're not going to be sitting this afternoon. The plan, and I'll double check when we get to that point, would be to return tomorrow at nine o'clock and pretty much relatively full day tomorrow and probably Friday as well. But I'll double check as we go through that. All right? And I'll let you know as soon as I can if there's any changes to that schedule. So with that, I'm going to ask the Commonwealth to call their next witness. Commonwealth?

Thank you. The Commonwealth calls Eitan Negri.

Good morning. Can you stop right here. Raise your right hand for the clerk.

Good morning. Do you solemnly swear that the testimony and evidence you shall give to the court and the jury in the matter [inaudible 00:05:16] the truth, the whole truth, and nothing but the truth, so help you God? Thank you. You may have a seat.

Watch your step, please.

All right. Good morning, sir.

Good morning, sir.

Can I just ask you to speak into that microphone.

Sure.

All right. Attorney Buckingham, please.

Thank you. Good morning, sir.

Good morning.

Could you please tell the jurors your first and last name?

My first name is Eitan. Last name is Negri.

Can you spell your first name for the record?

E-I-T-A-N.

And your last name?

N-E-G-R-I.

And what do you do for work?

I'm a physician associate, physician assistant.

And did you go to school for that?

Yes.

Can you tell us about your educational background?

I did my undergraduate at City College in New York, and I did a post-bacc at Brooklyn College followed by a PA program at Torah University in Manhattan.

And do you currently work as a physician's assistant?

Yes.

And do you currently work in the state of Massachusetts?

No, ma'am.

Are you licensed in the state of Massachusetts?

Yes, ma'am.

Are you licensed in any other states?

New York State.

I'm going to go back to January of 2023. Were you working in Massachusetts then?

Yes.

And where were you working?

Brigham and Women's Hospital.

And were you in that same role as a physician's assistant?

Yes.

And what were you doing? What were your general duties in that role working at Brigham and Women's?

Generally, you assess a patient, you diagnose, you formulate a plan with an attending physician, and you execute that plan throughout the day. It encompasses various things.

Were you working in any particular department at Brigham and Women's back in January of 2023?

Trauma burn surgical ICU.

Now I'm going to draw your attention to a particular patient that came into the Brigham and Women's Hospital on January 24th of 2023. That patient was Lindsay Clancy. Do you recall encountering this patient on January 25th of 2023?

Yes.

And what did you do as it pertained to the care and treatment of this patient?

I received the information from the shift before me, formulated a plan, examined her, assessed her, staffed that plan with the attending physician, and executed that plan throughout the day.

And fair to say this particular patient had injuries that you were directed to observe, review, form that plan on?

Correct.

What were the injuries?

She had multiple injuries. The most acute were injuries that were requiring consultation with other services. And the ones that I directly managed were the lacerations to her wrists and her ... Just her wrists, actually.

And as far as when you say she had other acute injuries, you were not involved in the care of her for those, correct?

I was involved in the care that involved consulting other services to manage those things, yes.

Okay. And as far as any sort of repair work that you were doing as a physician's assistant working with the trauma surgeons, what repair work were you assigned to do?

Laceration repair.

And on this particular patient, where were the injuries or lacerations that you were going to repair?

She had multiple lacerations on both of her wrists. She had superficial on her neck, which I did not repair.

Okay. And as it pertained to the wrists, did you go through that process of observing, reviewing, coming up with a plan and then repairing those injuries?

Yes.

And were you directed to do that by any particular doctor?

Not necessarily directed. A lot of those things fall within my scope, and since they were less acute, they kind of fell down the chain to me.

Okay. And you're aware that she was being seen and treated by a host of other doctors, nurses, an entire team?

Yes.

As it pertains to the wrist injuries, what did you do to examine those areas?

The first thing I do is assess the location, then I assess the severity, whether it requires intervention by someone other than myself. In this instance, it did not. So then I proceed with just kind of protocol laceration repair.

When would it be a situation where you'd need somebody else to intervene?

If it required surgical intervention or suturing repair beyond my skillset. In this instance, it did not.

Okay. And so referring to these particular injuries, when you observed them, did you observe any areas of active bleeding?

No.

And fair to say they had been treated by nurses and other staff prior to you encountering these injuries, correct?

Yes. They were dressed and covered before I got there.

Now, when you assessed them, you noted that they were bilateral, correct?

Yes.

What does that mean?

It means on both sides of the body, so both wrists.

Okay. And so referring to the right wrist, what were your observations of the injuries to the right wrist?

The right wrist, as far as my reference to the note, is that she had a few lacerations, one of which was severe and deep enough to require repair.

And fair to say that that right wrist injury was, the one that you repaired, was three centimeters deep?

Approximately. If that's what my note says, then that's what it was.

Okay. And on a wrist or this area of the wrist where you observed the injuries, that depth of three centimeters, did that require further surgical intervention or were you able to suture that area?

I was able to suture that area. As far as what happened subsequent to that, I wasn't there, so I'm not sure.

Okay. And how many sutures did you use to repair that injury?

I believe three.

And in relation to any other cuts or lacerations that were on that right wrist, did any other of those lacerations require suturing?

No.

How did you treat those other injuries?

Just irrigation, meaning cleaning them out, and then using a type of tape to close them shut.

And that's generally referred to as a Steri-Strip, correct?

Correct.

Okay. May I approach the witness?

You may.

I'm showing you two photographs. Do those photographs depict the repairs or the sutures that you did on the right wrist of Lindsay Clancy?

Yes.

I would move to admit these as the next two exhibits.

All right. Those may be admitted.

Exhibits 201 and 202.

Yes.

And I'm just going to show on the screen what's now been marked as Exhibit 201. And you should be able to see it, sir, on the screen in front of you. Can you see that?

Yes.

Okay. And so this is the right wrist, correct?

Correct.

And those black lines in the middle of the photograph, are those the sutures that you did?

Correct.

And just showing you 202, Exhibit 202, these white strips that are all around the injury, are those the Steri-Strips?

Correct.

Now on the left wrist, do you recall what you observed to be the injuries on that wrist?

I believe there was a similar laceration, just shorter in length that required fewer sutures.

Okay. And fair to say, if your notes reflect that the left wrist had one, meaning just a singular two centimeter deep linear cut, that that would've been what your observations were of the injury that you repaired?

Correct.

And how many sutures did that injury require?

One suture.

And were there other areas that you observed that had some sort of laceration?

I believe similarly, just superficial ones that needed Steri-Strips.

And again, in treating this particular injury, when you came upon it, was there active bleeding or any concern that you needed more intervention other than a suture?

At that time, no.

I'm going to show you two more photos. Are those familiar to you?

Yes.

And are those the suture that you did on the left wrist of Lindsay Clancy?

Yes, ma'am.

I move to admit these as the next two exhibits.

All right. They may be admitted.

Exhibits 203 and 204.

Thank you.

And now again, just showing what's been now marked as Exhibit 203. And you see the injury there on the wrist near the ruler in the photograph?

Yes.

And Exhibit 204, which is just a closer upshot of that, is that correct?

Yes.

And again, you see the white strips. Those are also Steri-Strips that were applied?

Correct.

Now in relation to any of these wounds on the right or the left wrist, did you observe the lacerations to go any deeper than the subcutaneous tissue?

On my observation, no.

Okay. And when we talk subcutaneous tissue, we're talking about that fatty tissue underneath your skin, correct?

Correct.

And did you have to return at any point, to your knowledge, to readdress these issues or do any further laceration repair as it pertained to this patient?

On that shift, no.

Do you recall if you did it on any other shift?

No.

I have no further questions. Thank you.

Mr. Reddington,

Is it Mr. Negri?

Negri. Yes, sir.

And you're not a doctor, you're a physician assistant. Is that what it is?

That's correct, yes.

Okay. And how long had you worked for Brigham and Women's prior to seeing Lindsay Clancy on January 24, '23?

I believe I was in my second year of employment with Brigham and Women's.

Okay. And you got to keep your voice up because people back here have to be able to hear you too, okay?

I believe I was in my second year of employment at Brigham and Women's.

You're not suggesting for one minute that after you did your butterfly stitches, Lindsay could have got up and walked out the door of the hospital, right?

No, sir.

And would you agree with me that, in fact, she was critically ill when you saw her, right?

Yes, sir.

And she certainly wasn't critically ill from COVID or a flu or something like that, right?

No, not to my knowledge.

You know that there are notes that are prepared for the records from the hospital. For example, on January 24, 2023, a hospital admission form is filled out. Do you know a Dr. Jeffrey Andrew Anderson?

Yes.

And what was his position that night?

He was one of the trauma surgeons and also one of the intensivists, the attending physicians in the ICU.

All right. And you've had a chance to review a number of records and photographs with the DAs, I imagine, right?

I've reviewed my own procedure note.

Okay. So what does that mean?

It means I reviewed the note that I wrote myself regarding the laceration repairs.

Okay. Is that the note that indicates that it appears as though that, for example, on the right upper extremity, there's a three and a half centimeter deep laceration on the volar aspect of the wrist?

I don't believe that I commented saying volar specifically, so I don't know if that's in regards to my note, but I believe my note did say about three centimeters deep, yes.

Okay. So do you recall indicating in your note that it was superficial laceration or did you indicate that it was a deep laceration?

I indicated that some of them were superficial and the one that I repaired in particular was three centimeters deep.

And you've had occasion to speak to the prosecutors on this case and that they've asked you about the superficial, superficial, superficial injury to her wrist, right?

Correct.

In addition to the, as indicated on page 75 of the Brigham Women's Hospital record that I have, and we can fix that with other records if it doesn't coincide, there's a note from Dr. Anderson that the right upper extremity, 3.5 centimeter deep laceration volar aspect of the wrist, left upper extremity, two centimeter deep laceration on the volar aspect of the wrist. Do you agree with that assessment?

Yes, sir.

All right. And then you were able to, as you say, clean it up with saline or whatever, and then you stitched up what you had to stitch up, right?

Yes, sir.

Did you have anything to do with the massive transfusion that she had?

No, sir.

Do you have anything to do with the treatment of the transected spine that she had, the shattered spine?

No, sir.

Do you have anything whatsoever to do with the insertion of tubes on both sides of her body and the draining of the blood that had pooled in her middle cavity?

Just the management of those tubes after, but not the placement.

Okay. So you were there while that was done?

I was there managing once they had been placed, but I was not there for the placement of the [inaudible 00:19:18].

Okay. But you knew that they were in there, that they were draining the blood?

Correct. Yes.

Okay. And do you know where the blood came from that was in her middle extremity?

I don't know specifically. I'd have to refer back to the imaging reports.

In any event, you know that shortly thereafter she coded, right?

Yes.

Were you there for that?

No, sir.

And basically that means that the patient has in effect died from cardiac arrest, right?

Not necessarily died, but their heart has stopped beating for that person, yes.

And hen there's crash teams and everybody hopefully revives the person, right?

Correct.

And you guys did that, or they did, and they were successful reviving her, correct?

Yes.

So without going through everything, you'd agree with me, sir, that your observations would be of the wrist, the repair, and taking care of the tubes after they were inserted into both sides of her chest?

That's correct.

And that was your involvement extended, correct? You're all done after that?

I was involved in the ongoing management of her care throughout the day, but just as you stated, not the things that you asked me about.

Okay. Thank you, sir.

Sure.

[inaudible 00:20:27].

They're part of the record. [inaudible 00:20:31]. I wouldn't object if we could approach.

I don't want to have a jury having to go through 10...

No, I know that. Listen, mark them for identification and then we can address that.

Thank you, sir.

Okay.

If I may, just got a few questions.

Sure.

Thank you. Mr. Negri, I'm just going to approach and show you.

Hold on a second. Is that my...?

[inaudible 00:20:51].

Thank you. All right. Thank you.

I'm going to show you a page from the records that's labeled Brigham and Women's Page 76. Can you just... You can hold it, that's fine.

Specifically this highlighted area?

Yeah, I would direct your attention to the bottom paragraph where it says exam.

Okay.

That's not your note from the record, correct?

Correct.

And when it's noted that the right upper extremity, left upper extremity has three and a half centimeter deep laceration, two centimeter deep laceration, "deep" in the medical notes is not a adjective of it, correct? It's more of a directionality of the injury.

It's a description of... Yeah, basically an objective unit of measure.

Okay. But when we say deep, it means that it goes down into the skin as opposed to across the skin.

It doesn't matter what we say, it's what the records say. I object to that.

[inaudible 00:21:57]. If you could ask that question again.

As far as your assessment of injuries, deep goes down in the skin as opposed to across the skin?

Correct.

Okay. And as far as Dr. Anderson goes, you knew him to be one of the attendings and a trauma surgeon in this case. Were you aware that on January 24th, he had examined these injuries and indicated they did not require repair at that time?

I don't recall specifically. I'm sorry.

But you came in to repair these on January 25th?

Yes.

Okay. Thank you.

Mr. Reddington, anything on that?

No, thank you, Judge.

All right. Thank you, sir.

Thank you.

You're welcome. You're all set. Attorney Buckingham, please.

The Commonwealth would call Nicholas Roberts as its next witness, please.

Good morning, sir.

Morning.

Can you stop right there and raise your right hand for the clerk, please?

Good morning. Do you solemnly swear that the testimony and the evidence you shall give to the court and the jury in the matter now pending between the Commonwealth and the defendant shall be the truth, the whole truth, and nothing but the truth, so help you God? Have a seat.

Watch your step, please.

Good morning, sir. All right, counsel.

Thank you. Good morning.

Good morning.

Could you please tell the jurors your first and last name?

It's Nicholas Roberts.

And where do you currently work?

I work for a company called Thermo Fisher.

What is that? What do they do?

They sell plenty of laboratory-based products, including refrigeration. They sell solvents. They do instruments as well.

Prior to working for that company, did you work for the Massachusetts State Police Crime Lab?

I did.

And in what unit did you work for the crime lab?

I was in the toxicology unit.

How long did you work for the crime lab?

For about nine years.

And in working for the crime lab, what kind of training and experience did you have to work in the toxicology unit?

So prior to being hired, I have both a bachelor's and a master's degree in applied forensic science with a concentration in chemistry and toxicology. I also have, the master's is in forensic toxicology. While being hired on the job, they provide training for all the in-house stuff that we test for, which includes not only a theory-based training, but also practical stuff so that you can analyze and run all the tests that we do in-house.

And as far as your work in the toxicology unit, fair to say in January of 2023 or February of 2023, you were what's referred to as a forensic scientist too, correct?

Yes.

And throughout your time at the Massachusetts State Police Crime Lab, did you have to undergo competency tests and proficiency tests?

Yes.

And why is that? Why do you have to do that?

So mainly it's to... [inaudible 00:25:33].

One at a time, okay.

I'm just saying I know he's qualified and I have no problem with his credentials and his testimony.

All right. All right. Counsel?

Thank you. Sir, in working at the State Police Crime Lab, did you just work in the toxicology unit or did you work in any other units in your time there?

No, only in toxicology.

Okay. Now, as it pertains to the toxicology unit, fair to say the State Police Crime Lab has a specific set of protocols and procedures that are followed in every case?

Yes.

Okay. And at that time in February of 2023, was the State Police Crime Lab using the batch review process?

Yes.

And so when the state police use this process, there are a number of different technicians or forensic scientists that work on any given case. Is that fair to say?

Yes.

And at the end of it, one analyst is responsible for reviewing all the data and authoring a report?

Yes.

And based on your training and experience, if you're that person reviewing the data and authoring the report, do you have the ability to interpret some of the data in the report?

Yes.

Or data in the testing, I should say.

Yes. We review all the data that is provided within the case file.

And did you, during your time at the crime lab in the toxicology unit, stay up to date on various types of drugs and quantifications of those drugs and what that could mean for levels in a person's blood or urine?

Yes. They keep us up to date on drugs that are commonly used.

So one of the roles in the toxicology unit is for you to report whether substances are detected in blood and urine. Is that fair to say?

Yes.

And at some points, are you also called upon to interpret the levels of those drugs?

So in blood, we report values. So we get concentrations of the different drugs. We mainly report them in blood.

Okay. And as far as the concentration levels themselves, did you have training and experience on interpreting those levels?

We usually get training on the effects of the drugs. It's hard to say with some drugs as well as some people what one level might mean for one person, it might differ and you have different effects on another.

Okay. And fair to say that's a limitation of just reviewing blood and not knowing anything else about a case, right?

Yes.

At the toxicology unit, at the crime lab, is there a limitation as to how or what types of drugs can actually be quantified or given concentration levels?

Yes, we only quantify certain drugs.

And what happens if there are other drugs present and there's a request for quantification or concentration levels? What does your lab do with that?

Usually they're sent out to another lab in order for testing.

And are you familiar with the NMS lab?

Yes.

Is that, or was that at that time, a common lab that would be sent drugs that you could not quantify in your lab?

Yes.

I'm going to direct your attention to the lab number of 23-01, excuse me. 01723. It's a case that you were the reporting analyst on, correct?

Yes.

And fair to say that there were several items that were submitted to the toxicology unit as specimens?

Yes.

Including blood, plasma, and urine?

Yes.

And did you work with other members of the toxicology unit to have those specimens screened and then further tested?

Yes. The batch process was followed.

And as far as any screening tests, did you yourself do any screening tests on these items?

Yes.

What screening tests did you do?

The screening for the alcohol.

And was there any alcohol present?

No.

And in this screening for alcohol, does it just tell you whether it was detected or not detected?

Yes.

Okay. And so when you don't have a result, there's nothing further to do?

Correct.

Now, as far as the blood that was tested in this case, and the urine, you were aware that there were screening tests done for what's called the ELISA screen, benzodiazepines, and general unknown screens for these samples, correct?

Yes, that's usually our protocol.

And in any of those circumstances, were there positive results?

Yes.

And as it pertained to the positive results, what's your understanding of what was positive?

So to my knowledge, it was positive for the benzodiazepine panel in ELISA. That would've gotten further confirmatory testing done on it to see the levels as well as the individual types of benzos that were present in the blood. And the same was for the urine as well. We also identified a few substances via our general unknown screen, which was confirmed in blood and urine.

Now as far as...

Counsel, wait, is there an agreement as to whose blood is being tested at this point instead of just by the number?

Yes.

It might be easier for everybody, for the jury to follow.

So would Your Honor just like me to read the results?

No, just instead of referring to it by a number... Well, let me see in sidebar.

Sir, I told you that your report was previously entered as Exhibit 183. Have you had the opportunity to review your report before coming today?

Yes.

And so the lab number that we've been referring to, you're aware that the person associated with that lab number was actually a woman by the name of Lindsay Clancy?

Yes.

Okay. Now, as far as the testing that was done, you received results to the positive benzodiazepines in the screen and then it was confirmed, correct?

Correct.

How many benzodiazepines were present?

There were at least four or five.

Okay. And were you able to get concentration levels from the blood samples after that screen and the confirmatory tests?

Yes.

And again, already in evidence, but the toxicology report for item 10-101 on the blood, with those benzodiazepines, there's diazepam, correct?

Yes.

Nordiazepam?

Yes.

Oxazepam?

Yep.

Temazepam?

Yes.

And Lorazepam?

Yes.

And as far as your review of the testing on those substances and the concentration levels, did anything about any of those levels stand out to you as far as based on your training and experience?

Only that they were reportable.

Okay. Are you familiar whether they're in any sort of therapeutic level for any of those drugs?

I'm not sure.

Okay. You mentioned there were also other substances that were detected in the general unknown screen, correct?

Yes.

And that would've been mirtazapine, lamotrigine, quetiapine, quetiapine metabolite, and Trazodone?

Yes.

And was your lab able to get concentration levels for those?

No.

And so what did you do or what was done with the samples or the specimens as it pertained to those substances?

To my knowledge, they were sent to NMS labs.

And you've previously stated that you are trained on effects of certain types of drugs, but your limitation is you don't know how it affects a particular individual, correct?

Correct.

These particular five benzodiazepines, do you know where they fall in the type of drug...

... do you know where they fall in the type of drug, what the general effects of those drugs are?

So benzos tend to be central nervous system depressants.

Okay. And the ones that were detected, but you don't have the levels for, mirtazapine, in the list I read, what category are those drugs?

Those tend to also be central nervous system depressants. Quetiapine in particular is usually known to treat bipolar disorder, schizophrenia.

And as it pertains to the presence of the five benzodiazepines, your testing is limited in that you don't know whether that was from one medication or multiple medications, correct?

Correct, because the nordazepam, oxazepam, and temazepam tend to be metabolites of diazepam.

Okay. I have no further questions.

All right. Attorney Reddington.

Morning.

Morning.

How you doing?

Not too bad. Yourself?

All right. Just a couple of brief questions. First of all, this would be a blood sample that was taken from Lindsay on a particular one day. This is not a panel of a bunch of different samples, right?

To my knowledge, there would've been a few different test tubes submitted to us. [inaudible 00:36:32].

Okay. Test tubes. In other words, when you draw the blood, it would basically be the same time that they put it in different test tubes?

Yes. I'm not familiar with these specific ones, like if they were done over a span of time, but usually-

That's fair. That's fair enough. But you have the test tubes and you know that it's Lindsay Clancy's blood, right?

Yes.

And you'd agree with me that that's a fairly large number of drugs and metabolites that are in that particular blood sample, right?

I have seen more.

I'm sure. But nevertheless, that's still a large number of drugs though, right?

Yeah, that's quite a few.

And you don't know, as working your job for the state police at that time, you don't know how many of these drugs are coming from scripts, prescriptions and things of that nature, right?

No.

One of the things that you had mentioned were metabolites, and you said that, because the district attorney asked you about different benzodiazepines, this pam, that pam, this pam, that pam, and then you responded and said, "Yeah, but there's a lot of metabolites involved in that." Right? What does that mean?

So a metabolite is just a breakdown of anything usually by the body. So you have what we call a parent drug and the body, if you ingest that, the body would then break it down or put it into a more digestible form in order to get rid of it.

Okay. So when you have a number of metabolites, for example, someone may have a prescription for amitriptyline or a prescription for Zoloft or Ativan or something, and they take the pill and it's in their system, and then over time it would metabolize and there'd be different pams or whatever it is that would break down into the blood. Is that right?

Yes.

How about tetrahydrocannabinols, THC, marijuana, what was the level on that?

To my knowledge, we didn't find any.

No marijuana, right?

Correct.

Thank you very much, sir.

All right. Attorney Buckingham, any redirect?

No, thank you.

All right. Thank you, sir. Please sit down over there.

Watch your step, sir.

Yeah?

[inaudible 00:38:45]. Sorry.

[inaudible 00:38:49].

[inaudible 00:38:50].

[inaudible 00:38:51].

Thank you.

Commonwealth.

Your Honor, at this time, upon agreement, I'd ask to admit as the next exhibit, just a chart that the parties have agreed upon that lists the brand names of some of the drugs that have been spoken about throughout the course of the trial, as well as what they were also known as for the ease of the jurors.

All right. [inaudible 00:39:09].

Yes, it's by agreement, Judge.

All right. All right. So by agreement, that may be admitted.

Exhibit 205.

And the Commonwealth would call Dr. Jonathan Brower as its next witness.

Good morning, sir.

Morning.

Can you stop right here and raise your right hand for the clerk, please?

Good morning. Do you solemnly swear that the testimony and the evidence you shall give to the court and the jury [inaudible 00:39:44] between the Commonwealth and the defendant [inaudible 00:39:46] shall be the truth, the whole truth, and nothing but the truth?

I do.

Thank you. You may have a seat.

Watch your step, please.

All right. Good morning, Doctor.

Good morning.

All right. Ask you to keep your voice up so the jury can hear you. And with that, counsel.

Thank you. Good morning, sir. Can you please tell the jurors your first and last name?

It's Justin Brower, B-R-O-W-E-R.

‍ And what do you do for work, sir?

I am a forensic toxicologist for NMS Laboratories.

And where is that laboratory located?

The laboratory is located in Horsham, Pennsylvania, just north of Philadelphia.

And what does your laboratory do?

We are a reference laboratory. We do postmortem work, clinical work, and forensic drug work. So primarily, my role is on the forensic side. I'm a forensic toxicologist.

And does your lab receive specimens from all across the country?

We do. We have clients in all 50 states. We do approximately half of the postmortem work in the United States, as well as a large number of clinical clients.

And is your lab accredited across several states and across the country?

We are, because we deal with all the states in the country, we are accredited by just about every accrediting body that I'm aware of in the clinical and forensic aspects, as well as a lot of state certifications. So a lot of states have their own requirements. The most notable one is New York State. So we're accredited by, again, every accrediting body that I'm aware of.

Okay. And how long have you worked for NMS Laboratory?

Four years as of August 1st.

And what's your educational background as a forensic toxicologist?

I have a PhD in organic chemistry.

Where did you get that from?

The University of Nevada.

And do you have any other professional experience in this field prior to working for NMS?

I do. Before joining NMS Laboratories, I was a laboratory supervisor and then forensic toxicologist for the North Carolina Office of the Chief Medical Examiner, which is a statewide system. So we did the postmortem toxicology work for all 100 counties of the state of North Carolina.

And when it comes to your role in the forensic area of doing the toxicology testing, what is your role in the NMS lab when it comes to cases that come to the laboratory for forensic analysis?

So when a case comes into NMS and is logged in and the assigned or the requested test assigned and then run and reviewed multiple times in the laboratory, when all that testing is completed, it comes to the toxicology department. And my role is to review every aspect of that case. So I'm making sure that everything on the toxicology report is complete and accurate, such as all the demographic information that we have available to us, the name of the decedent or the patient, date of birth, where it's from, the specimens that we received. And then also that everything that is reported is complete and accurate. Making sure that all the drugs that we're tested for are reported, that the reported concentrations are correct and accurate, and looking at every piece of raw data accumulated from the laboratory associated with that case.

Fair to say the NMS laboratory uses a batch review workflow?

That is correct. So we not only run the cases in batches, so we don't run one case at a time. That's not very efficient. I don't really know of any laboratory that does that anymore. So we will run cases 10, 15, 30 or 40 at a time.

So as far as running a particular test and getting the raw data, that's usually done by other people in the laboratory, correct?

That is correct.

And then you come in at the end and review everything and have the ability to interpret the data?

That is correct.

Your training and experience as a forensic toxicologist, does that allow you to interpret concentration levels of particular types of drugs?

It does.

Okay. Now, as far as the testing done at NMS Laboratories, the traditional testing is kind of the drug testing, the panels for different common drugs, correct?

Typically, we have a clients request panels to be run where we're looking for multiple drugs and classes of drugs at a time.

But are there circumstances when outside laboratories or outside individuals retain your lab in order to run specific tests?

Oh, absolutely.

Now, I'm going to draw your attention to this particular case. Was your laboratory provided a blood sample from the Massachusetts State Police Crime Lab in April of 2023?

I believe so. I'd really like to see the toxicology report so I can just confirm all of that, please.

Sure.

I have no objection to that.

Sure.

Thank you so much.

You can hang on to that.

That's fine.

Okay. Correct. We received the specimens on April 7th, 2023.

Okay. And it came from the Massachusetts State Police Crime Lab?

No. I don't know where they were initially sent from, but the client or the submitting agency is the District Attorney's Office of Plymouth.

Okay. Now, as it pertains to the requested testing that was done, was it that panel that you described or was it more specific testing?

This is what we call direct testing, where they requested just for specific drugs to be tested for.

And what were the four specific tests requested?

Lamotrigine, mirtazapine, quetiapine, and trazodone.

Are you familiar with those substances or those drugs?

Yes, ma'am.

Okay. And you reviewed all of the data and information done at your lab in regards to these tests, correct?

Yes, ma'am.

Were they able to identify concentration levels in the sample that was submitted for each one of those four substances?

Yes, ma'am.

And first, can you tell us what the result was?

Would you like me just to run down the list?

Sure.

Okay. We detected lamotrigine in a concentration of 6.1 micrograms per milliliter. Mirtazapine at a concentration of 200, I'm sorry, 200 nanograms per milliliter. Quetiapine at a concentration of 1,800 nanograms per milliliter, and trazodone at a concentration of 0.44 micrograms per milliliter. And these were all in blood.

In blood. And so with each drug that you just listed, are you familiar with what the common name is for the drugs?

I'm not always that great with common names, but I can wing it.

Okay. Well, the lamotrigine, and forgive me if I botch the-

That's okay.

... pronunciation. That's also referred to commonly as Lamictal.

It is, correct. Lamictal.

What kind of drug is that?

It's typically used as an anti-seizure medication. So if somebody has a seizure disorder, it can be prescribed to alleviate seizures, but it is also used for bipolar disorder as well.

And mirtazapine, fair to say that's commonly referred to as Remeron?

Correct.

And what kind of drug is that?

That is typically an antidepressant.

And quetiapine, what's that common drug?

Quetiapine is known as Seroquel.

And fair to say that's an antipsychotic as well for bipolar?

Yes, ma'am.

Are you familiar with whether that often can be prescribed in low doses for sleep?

It can be for insomnia.

And trazodone, what's the common name for trazodone, if you know?

I am drawing a blank on the trazodone.

If I suggest trazomine, is that familiar?

Not the one that I'm most familiar with. And I apologize. I only-

That's okay. But you're familiar with trazodone?

Correct. Yeah.

And what class of drug is that?

That's an antidepressant.

Okay. Now, in your review of the levels that were detected in these four tests for each of these substances, do any of these levels appear to be outside therapeutic concentration levels?

The only one that's a little elevated would be the quetiapine.

Okay.

We're going to take a very short break at this time. All right? So this will be a short break, then we'll come right back. All right?

Court, all rise. [inaudible 00:49:02] please close the notebook. [inaudible 00:49:04]. This way, please.

All right. We'll be right... This will be a short break just for a short recess. We'll come right back up.

Half hour?

Hopefully not. Mr. Stan, stand up.

This court is back in session. You may be seated.

All right. Are we all set for the jury? [inaudible 00:50:09].

[inaudible 00:50:11].

I think if you turn this on, you can watch it too.

Yeah. Thanks.

Court, all rise. Jurors entering. This court's now in session. Please be seated.

Your Honor, for the purpose of the record, we return back to the trial of Commonwealth versus Lindsay Clancy. All parties are present, including Ms. Clancy, and including the 18 jurors.

All right. All right. Counsel?

Thank you. Dr. Brower, before we broke, we mentioned the term therapeutic concentration. You familiar with that term?

Correct.

What does that mean?

It's the typical concentration that one would achieve when they're taking the medication or drug as indicated by their prescriber.

And are you familiar with toxic concentrations or suicidal concentrations?

I am.

And what does that mean?

Those are concentrations that could lead to adverse events and potentially death.

Now, in relation to the four substances that were tested at the NMS Laboratory, you identified the levels for each of the four substances. Were any of those levels, excuse me, concentration levels considered within therapeutic concentration?

It would all be in what I would say a therapeutic concentration, except maybe the quetiapine, which is slightly elevated.

Okay. And in your experience as a forensic toxicologist, have you had the occasion to review cases, postmortem cases in which suicide was a mechanism of death where the person consumed medication?

Absolutely, yes.

And so that level of the-

Quetiapine.

... quetiapine at the 800 nanograms per milliliter, would that have been in that toxic or suicidal level?

No, ma'am.

Would you generally expect to see that significantly greater in a suicide case?

Typically, quetiapines in suicide cases might be in the close to 10,000 nanograms per milliliter. Usually, people take handfuls of pills when they're trying to harm themselves and take their own life, and this is not consistent with that.

Now, are you also familiar in your training and experience with the class of drugs called benzodiazepines?

Yes, ma'am.

And do you have the occasion to interpret data as it pertains to concentration levels for those?

Every single day.

And as far as the substances diazepam, nordazepam, oxazepam, temazepam, lorazepam, you're familiar with those?

I am.

And if fair to say, nordazepam, oxazepam, temazepam, those are all metabolites of diazepam?

Typically, yes, ma'am.

And what's the common name for diazepam?

Valium.

Okay. If I show you what's been marked as Exhibit 183 already... Can you see that on the screen beside you?

I can, yes.

Okay.

Right there.

Can you see the levels?

They're all blurry.

Yep. Hold on one sec. There you go.

My eyesight's not great too, so that's perfect.

Okay. So that's best I can do with the autofocus.

Don't touch it.

Anything about the levels that you observed here regarding those substances, those benzodiazepines, that tell you that they're outside therapeutic concentration levels?

The diazepam and the nordazepam, oxazepam, and temazepam metabolites. The diazepam looks to be sub-therapeutic, meaning lower than what is typically expected from a therapeutic dose. Most therapeutic doses of diazepam, which is an anxiolytic drug or an antianxiety drug are typically 200, 250, thereabouts nanogram per milliliter. The lorazepam, depending upon the dose, could be a therapeutic concentration, if not maybe a little bit lower than expected.

Okay. Thank you. Now, when you're reviewing these cases as the reporting forensic toxicologist, are there limitations on what you can say about the effects of these types of medications?

We can speak as to the general effects that drugs can have on the general population, but we try to restrict ourselves from saying with absolute certainty that a drug will have this effect on this specific person because we just aren't there to witness their behavior.

Okay. So that was kind of the follow-up.

I'm sorry.

What are the things that are the unknowns for you when you're just looking at data?

We say that we can't do toxicology in a vacuum. You can't know everything about the case just by looking at numbers on the toxicology report and drugs on a toxicology report. You need other information to have an informed opinion. In the postmortem world, that would be the investigation itself, the history of the case, the scene findings, interviews with families and friends of the decedent, as well as autopsy findings as well. In a case like this, where it's not a decedent and the person is alive, you still need to know some facts of the case, some sort of history of the case, like what happened. So just numbers on a page. You can just make very generalized types of opinions such as that looks to be therapeutic, it looks to be high, it looks to be low. And then again, just the general effects on the drugs on people.

And in this particular instance, you were not provided any further information about the case or the investigation in order to make any more opinions about effects?

I knew nothing about this case until we spoke, I think it was probably a few weeks ago.

And as far as the information available to you, you only had the data from the specimen that was tested, correct?

That is correct. Just these four drugs that were requested to be tested for.

And as far as the drugs, the four drugs that were tested by your lab, what are the general characteristics of some of those drugs?

So these are generally antidepressants and antipsychotic medications. So if somebody had, well, the lamotrigine, if somebody has say bipolar disorder, like wild mood swings, depressive episodes or psychotic episodes, these drugs could be prescribed. They also have depressant effects, so they could make people become lethargic or sleepy.

Okay. And would any of the combination of these drugs cause a person to stop breathing?

It's possible. Especially the mirtazapine, quetiapine, the trazodone, and then the two other benzodiazepines. Those are all central nervous system depressants. So they could, in large combinations or large concentrations and in combination with each other, cause central nervous system depression, which could reduce people's respiration rates.

But in the levels that you observed in the testing that your lab did, as well as what I just showed you from Exhibit 183, is there anything about those concentration levels that would give you a sense that the person could have stopped breathing as a result of these?

Not necessarily, but if I had the information that a patient presented to an emergency department and they had labored breathing and weren't breathing adequately and I had this information, then you could probably tie all that together. But without that extra information, then generally no.

Based on the levels alone, you can't give any sort of opinion?

I would like to not.

Okay. And finally, are you familiar with the drug Narcan?

I am.

And what kind of effect does the drug Narcan have on a person who has consumed these drugs, if any?

Just these drugs that we've talked about here today?

Mm-hmm. Yes.

Absolutely nothing.

Can you explain to us why it is that Narcan wouldn't have an effect?

Narcan is an opioid overdose reversal agent. It is an opioid antagonist. So it binds to the opioid receptors. So it doesn't allow other opioids like say fentanyl or oxycodone to bind to those receptors to have to exert its effects. So it only works on opioids. None of these drugs work on the opioid receptors. So Narcan would have no effect whatsoever on these drugs.

Okay. Thank you.

Attorney Reddington.

Good morning.

Good morning.

Dr. Brower, so one of the things that you had mentioned is that you, and I think I would quote you, "I would like not to give an opinion without, basically, the underlying facts." In other words, what you're saying is that the numbers alone do not tell the tale of what happened to a particular individual, right?

Correct. They don't tell the entire story.

Right. And you're for NMS Laboratory, you were retained or working for the DA's office, these people here, right?

That was the submitting agency, correct.

And they certainly were not constrained from picking up the phone and calling you and telling you that this is blood from a woman that threw herself out a window and tried to kill herself after cutting her wrists and her neck. They could have told you that, right?

Well, overruled.

It's possible that does happen in rare occasions in high profile cases.

Right. And so that would have been something, for example, the facts that you wanted to know, that you would have liked to have known to kind of round out your opinion about the actual level of the drugs and the blood that you examined, right?

It's not necessary.

Well, it's not necessary, but you did indicate that you would like to not give an opinion without the facts.

Correct.

Okay.

Today.

From the witness stand?

Correct. I don't have all the information.

Of course. And the word therapeutic, is that consistent with, in other words, the treatment level of a particular narcotic or drug in the blood?

Correct. It's the concentration of the drug in the body to elicit an effect or the desired effect.

[inaudible 01:02:26].

[inaudible 01:02:32].

Yeah, I think [inaudible 01:02:33]. Thank you. [inaudible 01:02:42]. One of these that I introduced [inaudible 01:02:46]. NMS Laboratory records that I introduced that they were marked for ID.

Which one, this?

Huh?

[inaudible 01:03:02]?

Yeah.

[inaudible 01:03:04]. Which one?

Marked yesterday.

[inaudible 01:03:11] while she's trying to find the record. As it relates to the therapeutic level, sir, is it your understanding that the lorazepam, the alprazepam, clonazepam, counsel had asked you about the benzodiazepines were within therapeutic, thank you, within therapeutic level?

I'm sorry, I had trouble hearing you.

Yeah, I'm sorry. They were within therapeutic level?

I'm sorry, can you repeat the entire question?

Sure. What is lamotrigine?

Lamotrigine is typically used as an anti-seizure medication and could also be used for bipolar disorder.

Okay. Do you have the results for your lab in front of you?

Yes, sir.

Yeah, you can read along just so you can refresh your memory if it helps. The lamotrigine, it says 6.1. What does that mean?

6.1 micrograms per milliliter. So there were 6.1 micrograms of lamotrigine per milliliter of blood.

All right. Is that above therapeutic, below therapeutic, or therapeutic?

It's right in the middle of the therapeutic range.

So if somebody had a prescription, for example, for that narcotic or that drug, then they were taking the drug according to the recommended dose, right?

That's what it would appear to me if they were prescribed it, correct.

How about the mirtazapine?

The mirtazapine also looks to be probably used appropriately as prescribed.

And you need a prescription for that, don't you?

Yes. You need a prescription for all three, I'm sorry, all four of these drugs.

Okay. And is there another name for mirtazapine?

Remeron.

Remeron. All right. And what is the purpose or what do you use Remeron for?

It's an antidepressant.

How about the quetiapine is the number three?

The quetiapine is also known as Seroquel, and that is generally used as an antipsychotic.

And what does that mean when you say an antipsychotic? What does that mean?

So if somebody has psychotic episodes, say like hallucinations or just not seeing reality like, "normal" person would, they could be prescribed quetiapine as an antipsychotic to try to kind of level out their brain chemistry.

And what was the result on the quetiapine?

1,800, 1,800 nanograms per milliliter.

Now is that within therapeutic? Is that below or high?

It looks high to me depending upon the dosage.

Okay. And trazodone is the next one. What is that?

Trazodone is also an antidepressant.

And what's the result on that?

Oh, I'm sorry. 0.44 micrograms per milliliter.

Okay. And is that therapeutic, below therapeutic, or above therapeutic?

I would say that's a therapeutic concentration.

Okay. So basically, with the exception of the quetiapine that was 1,800 nanograms... What is a nanogram? What does that mean? Nanograms per milliliter. What does that mean?

It's a very, very small amount. It's one-millionth of a milligram.

Okay. And that's how you measure the quantity of a particular substance that would be in a person's blood, correct?

In the blood, correct.

So on the quetiapine at 1,800 nanograms per milliliter, that's the only one that was not therapeutic. That was a little higher than therapeutic. Is that correct?

Correct. It's approximately maybe double what you might expect. So when I say it's a little elevated, it's not in a concentration that I would consider to be necessarily toxic or lethal.

Okay. And you don't know working for NMS Labs or whether or not a person had a prescription for these drugs or when they got the prescription or who gave them the... You don't know that, right?

I have none of that information, no.

You could have known that if somebody had told you that, but you don't know it from looking at the numbers that we have here, right?

Correct. It's possible if they would've given us that information. We don't always need to have it though.

Sure. Your Honor, this is what I [inaudible 01:07:45].

Can I just see it again first?

Oh, sure.

[inaudible 01:07:53].

Yep.

[inaudible 01:07:54]. If we can just approach briefly on the issue.

Yeah. All right. So we're going to introduce that exhibit at this time.

Thank you.

106

So just if I may, excuse me, approaching. Which basically is an NMS Lab report.

Same as this one.

Same numbers on the top, right? Where the square is?

Correct.

Same numbers. Okay.

Correct.

Thank you, sir. That's all I had.

All right.

All right. Yeah. Commonwealth?

Dr. Brower, you in fact, once got this case for review, you authored a corrected report in regards to this case, correct?

Correct.

At this point, I would move to admit the report as such.

No objection.

All right. That may be admitted as well.

Thank you.

Exhibit [inaudible 01:09:11].

Nothing further.

I have nothing further. Thank you, sir.

All right. Thank you, Doctor.

Am I released?

Who else? Thank you.

Thank you.

Watch your step.

[inaudible 01:09:28].

[inaudible 01:09:28].

Your Honor, prior to the next witness, the Commonwealth would move to submit four stipulations the parties have entered into. The first being a stipulation regarding DNA known standard samples. The second being a stipulation regarding DNA evidence for the blue exercise band and the red-brown stain on the basement floor. The third being the stipulation regarding DNA evidence for the yellow exercise band and the black exercise band. And the fourth being a stipulation regarding DNA comparisons for the blue exercise band and the red-brown stain in the basement.

That's right. We don't need to have all...

... and in the red brown stain in the basement.

That's right. We don't need to have all those witnesses.

All right. So those stipulations may be entered as exhibits. Counsel, do you want those published or read to the jury or satisfied that they'll have those? And the parties can refer to the contents of the stipulations.

[inaudible 01:10:34] Yeah.

The only one we would like to have to have read to the jury... I'm sorry, are you all set?

[inaudible 01:10:42].

Take your time.