Suicide Celexa 2011-04-19 California Woman Kills Self: Medical Examiner Believes Celexa Contributed to her Suicide
Summary:

This article states:  "The Coroner's autopsy report ascribed Elbert's death to "multiple drugs toxicity" and identified the manner of death as suicide."

On November 21, 2007, the Los Angeles County Department of Coroner, Forensic Science Laboratories issued Elbert's toxicology report. That report found no detectable levels of alprazolam (Xanax) in Elbert's blood. That report recorded levels of citalopram (Celexa) of 0.57 micrograms per milliliter in the femoral sample, and 0.44 micrograms per milliliter in the heart sample. The declaration of defendants' expert witness, Ronald L. Alkana, Pharm.D., Ph.D., stated that although these levels of citalopram [Celexa] were high, they were not lethal to human beings, and if Elbert had taken citalopram (Celexa) as directed by her physician and as written on her prescription label, she would not have reached these levels. Alkana stated that citalopram taken as directed by Elbert's physician would not have caused her death. The declaration of plaintiff's expert witness, Marvin Pietruszka, M.D., M.Sc., F.C.A.P., stated that a study of 12 deaths related to citalopram use found average concentrations of 0.5 micrograms per milliliter with a range of 0.1-1.3 micrograms per milliliter to be a causative metabolic factor in the investigated deaths. Ogbonna Chinwah, M.D., a deputy medical examiner for the Los Angeles County Coroner, conducted the autopsy on Elbert and prepared the autopsy report. Chinwah testified that the lethal range for citalopram is 0.24 to 1.3; citalopram in Elbert's blood was 0.57; and that citalopram was "within the lethal range." Chinwah believed that citalopram caused or contributed to Elbert's death.


http://www.leagle.com/xmlResult.aspx?xmldoc=In%20CACO%2020110419020.xml&docbase=CSLWAR3-2007-CURR


ELBERT v. KHOSSOUSSI

DOROTA S. ELBERT, Plaintiff and Appellant,
v.
FARHAD KHOSSOUSSI et al., Defendants and Respondents.

No. B221918.

Court of Appeals of California, Second District, Division Three.

Filed April 19, 2011.

Daniel M. Graham, for Plaintiff and Appellant.
Dunbar & Associates,
Kevin T. Dunbar and David V. Harris for Defendant and Respondent Thrifty Payless, Inc.
Law Offices of Kenneth W. Drake & Associates,
Kenneth W. Drake, Jamie Diamond and Kenneth Robert Myers for Defendant and Respondent Farhad Khossoussi, M.D.

 

 
NOT TO BE PUBLISHED IN THE OFFICIAL REPORTS
KITCHING, J.
INTRODUCTION
Plaintiff Dorota S. Elbert appeals from a judgment entered after the trial court granted the motions for summary judgment of defendants Rite Aid, a dba of Thrifty Payless, Inc. (Rite Aid), and Farhad Khossoussi, M.D. in Elbert's suit for medical negligence and pharmaceutical negligence arising from the death of plaintiff's daughter. We find that the trial court erroneously sustained defendants' objections to the declaration of plaintiff's expert medical witness, but did not erroneously overrule plaintiff's objections to the declaration of defendants' expert witness. The summary judgment motion was made and granted on the issue of the causation of decedent's death. Because the evidence shows that a triable issue of fact exists as to causation, we reverse the judgment.
FACTUAL AND PROCEDURAL HISTORY
On October 15, 2007, Lorian T. Elbert was found unresponsive, in bed, with a plastic bag over her head. Los Angeles Fire Department paramedics responded and pronounced death at 1:55 p.m. Los Angeles County Coroner's Department investigators searched Elbert's bedroom. They found a suicide note that indicated Elbert's depression and suicidal intent and medication bottles and pills on a night stand in Elbert's room. Medical evidence collected from Elbert's residence included 56 tablets labeled TYC 365; one empty bottle of Tylenol PM tablets; one bottle containing 33 acetaminophen soft gels; alprazolam prescription medication (Xanax) dispensed by Rite Aid on October 3, 2007; and Ambien prescription medication dispensed by Rite Aid on October 12, 2007.
On October 3, 2007, Rite Aid Pharmacy had dispensed to Elbert one prescription for citalopram (the generic ingredient in the medication Celexa) for a total of 30 pills, and one prescription for alprazolam (the generic ingredient in the medication Xanax) for a total of 20 pills. On October 12, 2007, Elbert had one Ambien prescription for a total of 30 pills filled by Rite Aid Pharmacy.
The Coroner's autopsy report ascribed Elbert's death to "multiple drugs toxicity" and identified the manner of death as suicide.
On November 21, 2007, the Los Angeles County Department of Coroner, Forensic Science Laboratories issued Elbert's toxicology report. That report found no detectable levels of alprazolam (Xanax) in Elbert's blood. That report recorded levels of citalopram (Celexa) of 0.57 micrograms per milliliter in the femoral sample, and 0.44 micrograms per milliliter in the heart sample. The declaration of defendants' expert witness, Ronald L. Alkana, Pharm.D., Ph.D., stated that although these levels of citalopram were high, they were not lethal to human beings, and if Elbert had taken citalopram (Celexa) as directed by her physician and as written on her prescription label, she would not have reached these levels. Alkana stated that citalopram taken as directed by Elbert's physician would not have caused her death. The declaration of plaintiff's expert witness, Marvin Pietruszka, M.D., M.Sc., F.C.A.P., stated that a study of 12 deaths related to citalopram use found average concentrations of 0.5 micrograms per milliliter with a range of 0.1-1.3 micrograms per milliliter to be a causative metabolic factor in the investigated deaths. Ogbonna Chinwah, M.D., a deputy medical examiner for the Los Angeles County Coroner, conducted the autopsy on Elbert and prepared the autopsy report. Chinwah testified that the lethal range for citalopram is 0.24 to 1.3; citalopram in Elbert's blood was 0.57; and that citalopram was "within the lethal range." Chinwah believed that citalopram caused or contributed to Elbert's death.
The Coroner's toxicology report recorded levels of norcitalopram of 0.28 micrograms per milliliter. Chinwah testified that norcitalopram is a metabolite or breakdown product of citalopram. Chinwah believed that norcitalopram caused or contributed to Elbert's death.
The Coroner's toxicology report recorded levels of zolpidem (an ingredient in Ambien) of 3.0 micrograms per milliliter in the femoral sample and 1.6 micrograms per milliliter in the heart sample. Alkana stated that these levels of Ambien were high but not lethal, and that if Elbert had taken Ambien as directed by her physician, Ambien would not have reached these levels and would not have caused her death. Pietruszka stated that a fatal dose of zolpidem is considered to be in the 0.8-0.9 micrograms per milliliter level and that decedent Elbert's level of zolpidem was fatal. Chinwah testified that the zolpidem level was within the lethal level of 1.1 to 3.2. Chinwah believed that zolpidem caused or contributed to Elbert's death.
The toxicology report recorded levels of diphenhydramine (an ingredient in Tylenol PM) of 22 micrograms per milliliter in the femoral sample and 15 micrograms per milliliter in the heart sample. Alkana stated that this level of diphenhydramine is well above the minimum concentration of diphenhydramine lethal to human beings, and that by taking the manufacturer's recommended dose of this drug someone would not reach these concentration levels. Pietruszka stated that the diphenhydramine found at the level of 22 micrograms per milliliter was considered in a fatal range. Chinwah testified that the lethal level of diphenhydramine was above 8 micrograms per milliliter, and that 22 micrograms per milliliter of diphenhydramine was in the lethal range. Chinwah believed that diphenhydramine caused or contributed to Elbert's death.
Alkana stated his opinion that within a reasonable degree of medical certainty, diphenhydramine from over-the-counter medication Tylenol PM caused Elbert's death. Alkana also stated his opinion that within a reasonable degree of medical certainty, the alprazolam, citalopram (Celexa) and Ambien dispensed by Rite Aid on October 3 and 12, 2007, taken as directed by Elbert's physician and as clearly written on her prescription label, would not have caused Elbert's death.
Alkana stated that Elbert would have had to ingest a minimum of 100 Tylenol PM pills over a short period of time in order to reach the lethal levels of 22 micrograms per milliliter in the femoral sample and 15 micrograms per milliliter in the heart sample found in Elbert's post-mortem blood by the Coroner's Department toxicologist.
Alkana stated that no one ingests by accident, over a short period of time, the number of Tylenol PM pills taken by Elbert to reach these lethal blood levels. Alkana stated that Elbert's taking of excessively large amounts of Tylenol PM was an intentional act. Alkana stated his opinion that Elbert succeeded in committing suicide by ingesting lethal amounts of the over-the-counter medication Tylenol PM.
Dr. Chinwah did not request that the toxicology report test for acetaminophen (an ingredient in Tylenol PM), and the toxicology report did not test for acetaminophen.
On December 17, 2008, plaintiff Dorota S. Elbert, the mother of Lorian T. Elbert, filed her complaint for wrongful death based on medical negligence against Farhad Khossoussi, M.D. and based on pharmaceutical negligence against Rite Aid Pharmacy. Rite Aid filed a motion for summary judgment on August 25, 2009, which motion defendant Khossoussi joined on September 1, 2009. After plaintiff filed opposition and defendants filed replies, the trial court sustained defendant's objection to paragraph 3 of the declaration of plaintiff's expert witness Pietruszka, determined that there was no triable issue of fact, and granted summary judgment for defendants. Judgment for defendants was entered on December 14, 2009. Elbert filed a timely notice of appeal.
ISSUES
This appeal presents the following issues:
1. Whether the trial court improperly sustained defendant's evidentiary objections to the declaration of plaintiff's expert Marvin Pietruszka, M.D.;
2. Whether the trial court erroneously overruled plaintiff's objections to the declaration of defendant's expert, Ronald L. Alkana, Pharm.D., Ph.D.; and
3. Whether the evidence created a triable issue of fact as to the causation of decedent Elbert's death.
DISCUSSION
1. Objections to Statements in Pietruszka's Declaration Concerning Rite Aid's Duty of Care Were Properly Excluded as Addressing Issues Outside the Scope of the Summary Judgment Motion, but Exclusion of the Remainder of Paragraph 3 of the Declaration Was Error
A. The Objection to the Declaration of Plaintiff's Expert Witness Dr. Pietruszka
Rite Aid filed objections to the declaration of plaintiff's expert witness, Marvin Pietruszka, M.D. The trial court sustained objections to paragraph 3 of Pietruszka's declaration.
Paragraph 3 stated that a study showed that average concentrations of citalopram (Celexa) of 0.5 micrograms per milliliter with a range of 0.1-1.3 micrograms per milliliter to be a causative metabolic factor in the investigated deaths. The Coroner's report recorded levels of citalopram (Celexa) of 0.57 micrograms per milliliter in decedent Elbert's femoral sample, and 0.44 micrograms per milliliter in the heart sample. Paragraph 3 stated that to a reasonable degree of medical probability, both the citalopram (Celexa) and zolpidem (Ambien) caused and/or contributed to Elbert's death. Pietruszka cited the Coroner's toxicology report finding that Elbert's femoral blood specimen showed 3.0 micrograms per milliliter of zolpidem (Ambien), and stated that a fatal dose is considered to be in the 0.8-0.9 micrograms per milliliter level. Pietruszka stated that to a reasonable degree of medical probability zolpidem (Ambien) was a primary factor in causing or contributing to Elbert's death. Pietruszka further stated that the level of diphenhydramine (Benadryl) was fatal. Pietruszka concluded that based on the Coroner's toxicology report, the combination of drugs principally responsible for causing Elbert's death were diphenhydramine (an ingredient of Tylenol PM) and zolpidem (Ambien) dispensed by Rite Aid.
The final part of paragraph 3 of Pietruszka's declaration stated that the fact that Elbert was seeking psychiatric help lead him to assume that the quantity of multiple drugs should not be placed in the possession of a severely depressed patient, such as Elbert. Moreover, because "multiple drugs toxicity" caused the death, Pietruszka stated that Dr. Alkana's conclusion (that if Elbert had taken citalopram (Celexa), Ambien, and Tylenol PM as directed by her physician or by the manufacturer, she would not have reached these levels) was factually unsupportable, because the cause of death was not one drug or medication, but was multiple drugs, all of which were prescribed and dispensed by defendants to a depressed individual in quantities beyond any therapeutic purpose. Pietruszka also stated that alprazolam (Xanax) and citalopram (Celexa) have noted side effects of causing or elevating suicide ideology.
Rite Aid objected to Paragraph 3 as inadmissible expert testimony, and vague, ambiguous, speculative, and conclusory allegations; argued that Pietruszka's statements misstated the evidence and introduced hypothetical examples in a blatant attempt to create triable issues of fact; and stated that Pietruszka's statements were irrelevant to issues raised by the summary judgment motion in that his opinions addressed the standard of care of dispensing prescription medications rather than the issue of medical causation. As stated, the trial court sustained objections to Paragraph 3 of Pietruszka's declaration.
This court reviews a trial court's evidentiary rulings in a summary judgment motion for abuse of discretion. (Mitchell v. United National Ins. Co. (2005) 127 Cal.App.4th 457, 467.)
B. Objections to Statements in Pietruszka's Declaration Concerning Rite Aid's Duty of Care Were Properly Excluded, But the Ruling Excluding the Remainder of Paragraph 3 of That Declaration Was Error
Defendant's objection to Pietruszka's declaration did not quote or set forth the objectionable statement or material, and did not state the grounds for each objection to that statement or material, in violation of California Rules of Court, rule 3.1354(b).
Defendant objected to paragraph 3 of Pietruszka's declaration as inadmissible expert testimony, but makes no explanation why it was inadmissible. Defendant also objected to paragraph 3 as vague, ambiguous, speculative, and conclusory allegations, but again failed to explain what matter in paragraph 3 suffered from these defects and why it should therefore be ruled inadmissible. Defendant's brief on appeal contains no further explanation of these purported defects.
Pietruszka's declaration stated that it was based on his review of the Los Angeles County Coroner's report of Elbert's death, the Coroner's Forensic Science Laboratory's toxicology report, case report, description of medical evidence, investigator's narrative report, and Elbert's pharmacy records from Rite Aid Pharmacy and Dr. Khossoussi's consult note. The declaration set forth Pietruszka's academic and medical credentials, which include board certification by the American Board of Pathology, the American Board of Preventive Medicine, and the American Board of Forensic Toxicology, membership in the American Academy of Clinical Toxicology, and a practice as a pathologist and toxicologist in the Southern California medical community, and director of a toxicology laboratory. The declaration concluded that citalopram (Celexa) and zolpidem (Ambien) caused and/or contributed to Elbert's death. This conclusion was based, first, on a study finding that 12 deaths related to citalopram use found average concentrations of 0.5 micrograms per milliliter with a range of 0.1-1.3 micrograms per milliliter to be a causative metabolic factor in the investigated deaths. The Coroner's report recorded levels of citalopram (Celexa) of 0.57 micrograms per milliliter in decedent Elbert's femoral sample, and 0.44 micrograms per milliliter in the heart sample. This conclusion was based, second, on the finding in the Coroner's toxicology report that zolpidem was found in Elbert's femoral blood at the level of 3.0 micrograms per milliliter, and a fatal dose was considered to be in the 0.8-0.9 micrograms per milliliter level. The declaration states the further conclusion, with reference to the Coroner's report stating the cause of death as "multiple drugs toxicity" and the femoral and heart blood specimens in the Coroner's toxicology report, Elbert's death was caused by the combination of diphenhydramine and zolpidem (Ambien), the latter of which was dispensed by defendant Rite Aid. These statements are not vague, ambiguous, speculative, or conclusory allegations, and exclusion of Pietruszka's declaration on that basis was an abuse of discretion.
More specifically, Rite Aid objected that statements in Pietruszka's declaration1 were irrelevant to issues raised by the summary judgment motion, in that some of Pietruszka's broadly worded opinions were directed to the standard of care of dispensing prescription medications rather than to the issue of medical causation. This objection was well-taken, as the summary judgment motion argued exclusively in terms of a lack of causation. Rite Aid's summary judgment motion alleged that Lorian T. Elbert took a lethal dose of an over-the-counter medication, Tylenol PM, containing diphenhydramine; that the level of diphenhydramine found in Elbert's post-mortem blood samples was well above the minimum concentration known to be lethal; that the other drugs she ingested were above therapeutic levels but not in the lethal range; and that therefore plaintiff had not shown the causal connection sufficient to establish the liability of Rite Aid for Elbert's death. Specifically, the motion argued that plaintiff could not establish that the alprazolam (Xanax), citalopram (Celexa), or Ambien dispensed by Rite Aid caused Elbert's death. Consequently the first five sentences of subparagraph (g) of Paragraph 3 of Pietruszka's declaration were properly excluded.
It was error, however, to exclude the remainder of paragraph 3 of Pietruszka's declaration.
2. Plaintiff Has Not Shown Error in the Overruling of Objections to the Declaration of Defendants' Expert Witness
A. Plaintiff's Objections to the Declaration of Dr. Alkana
Plaintiff filed objections to the declaration of Ride Aid's expert witness, Ronald L. Alkana, Pharm.D., Ph.D. The trial court made no express ruling on the objections, which are not waived on appeal. (Reid v. Google, Inc. (2010) 50 Cal.4th 512, 531-532.)
Plaintiff objected to Alkana's statement that "[w]hen deaths are investigated by members of the Los Angeles County Coroner's Department, it is a standard practice" of the Coroner's Department to search the decedent's residence for prescription medication, and that it is a standard practice "in the community" to record all over-the-counter and prescription medication found in that residence. Plaintiff objected to these statements as lacking in foundation, in that the declaration does not state Alkana's knowledge of or familiarity with what is "standard practice" employed by the Los Angeles County Coroner's Department or by "the community," which community is not identified.
Plaintiff objected to Alkana's statement that the decedent "would have had to ingest a minimum of 100 Tylenol PM pills over a short period of time in order to reach the lethal levels" of diphenhydramine in the femoral and heart samples. Plaintiff also objected to Alkana's statement that based on his skill, training, and experience, "within a reasonable degree of certainty [d]iphenhydramine, from the over-the-counter medication Tylenol PM caused the Decedent's death." Plaintiff objected to the first statement (that the decedent would have to ingest 100 Tylenol PM over a short time to reach lethal levels) as speculation, in that Tylenol PM contains 75 percent acetaminophen and 25 percent diphenhydramine, and the Coroner's toxicology report had no indication that acetaminophen was found in the decedent's blood. Plaintiff also objected that these statements lacked foundation because Alkana was a pharmacist and not a licensed physician, and lacked the training, education, experience and stated expertise to render an opinion as to cause of death.
Plaintiff objected to Alkana's statements in several paragraphs "within a reasonable degree of medical certainty," because Alkana is not a licensed physician and any opinion about what did or did not cause decedent's death was beyond his training, education, experience, and expertise.
As stated, the trial court made no ruling on plaintiff's objections.
B. Plaintiff Has Not Shown Error in the Overruling of Objections to Dr. Alkana's Declaration
The grant of the summary judgment motion did not rely on Alkana's statements that it was standard practice of the Los Angeles County Coroner's Department to search a decedent's residence for prescription medication. In any case plaintiff did not dispute that Coroner's Department investigators searched Elbert's bedroom at the time of her death and recovered TYC 365 tablets, an empty Tylenol PM bottle, 33 acetaminophen soft gels, alprazolam prescription medication, and Ambien prescription medication. Plaintiff, moreover, does not argue on appeal that the trial court erroneously overruled this objection to Alkana's declaration.
Plaintiff also objected to Dr. Alkana's statement that the decedent would have to ingest 100 Tylenol PM over a short time to reach lethal levels of diphenhydramine as speculation, in that Tylenol PM contains 75 percent acetaminophen and 25 percent diphenhydramine and the Coroner's toxicology report had no indication that acetaminophen was found in the decedent's blood. As plaintiff points out in another context, Dr. Chinwah of the Coroner's Department did not request that the toxicology report test for acetaminophen, and acetaminophen was not tested for the toxicology report. Thus the absence of acetaminophen does not make Alkana's statement speculation.
Plaintiff objected to this statement, and statements in several paragraphs "within a reasonable degree of medical certainty," because Alkana is not a licensed physician and any opinion about what did or did not cause decedent's death was beyond his training, education, experience, and expertise. Alkana, however, was a pharmacist licensed by the California State Board of Pharmacy. The Legislature has declared the practice of pharmacy to be a profession (Bus. & Prof. Code § 4050, subd. (a)) and has described pharmacy practice as a "patient-oriented health service that applies a scientific body of knowledge to improve and promote patient health by means of appropriate drug use, drug-related therapy, and communication for clinical and consultative purposes." (Id. at subd. (b).) Alkana had a Pharm.D. degree from the University of Southern California School of Pharmacy and a Ph.D. in Psychobiology from the University of California at Irvine. Alkana was Professor of Molecular Pharmacology and Pharmaceutical Sciences and Associate Dean of Graduate Studies and Curricular Development at the University of Southern California School of Pharmacy. Alkana's declaration stated that in his 30-year academic and professional career, he was actively involved in the toxicological analysis of individuals from a pharmacological standpoint, which included pharmacological and toxicological analysis of individuals ingesting alprazolam, citalopram, Ambien, Tylenol, and diphenhydramine and analysis of the effects of those medications on the human body at the sub-therapeutic, therapeutic, toxic, and lethal levels. Thus Alkana's training, education, experience, and expertise provided him with a basis for stating the effects of those medications "within a reasonable degree of medical certainty."
We find no error in the overruling of plaintiff's objections to Alkana's declaration.
3. The Evidence Created a Triable Issue of Fact as to the Cause of Lorian T. Elbert's Death, Requiring Reversal of Summary Judgment
Defendants moved for summary judgment on evidence, in the form of Dr. Alkana's expert witness declaration, that recorded levels of prescription drugs in Elbert's blood samples were not lethal, and that the level of diphenhydramine found in non-prescription, over-the-counter Tylenol PM was found in Elbert's blood samples well above the level known to be lethal to human beings, and that diphenhydramine from over-the-counter Tylenol PM caused Elbert's death. Other evidence, however, created a triable issue of fact as to the drugs that caused Elbert's death.
Dr. Alkana's expert witness declaration stated that recorded levels of citalopram (Celexa) (0.57 micrograms per milliliter femoral sample and 0.44 micrograms per milliliter heart sample) were not lethal. The declaration of plaintiff's expert witness, Dr. Pietruszka, stated that a study of 12 deaths related to citalopram use found average concentrations of 0.5 micrograms per milliliter with a range of 0.1-1.3 micrograms per milliliter to be a causative metabolic factor in the investigated deaths. Ogbonna Chinwah, M.D., a deputy medical examiner for the Los Angeles County Coroner, testified that the lethal range for citalopram is 0.24 to 1.3; that citalopram in Elbert's blood was .57; and therefore citalopram was "within the lethal range." Dr. Chinwah believed that citalopram caused or contributed to Elbert's death.
The toxicology report recorded levels of norcitalopram of 0.28 micrograms per milliliter. Dr. Chinwah testified that norcitalopram is a metabolite or breakdown product of citalopram. Dr. Chinwah believed that norcitalopram caused or contributed to Elbert's death.
The toxicology report recorded levels of zolpidem (an ingredient in Ambien) of 3.0 micrograms per milliliter in the femoral sample and 1.6 micrograms per milliliter in the heart sample. Dr. Alkana stated that these levels were high, but not lethal. Dr. Pietruszka stated that a fatal dose of zolpidem is considered to be in the 0.8-0.9 micrograms per milliliter level, and that Elbert's level of zolpidem was fatal. Dr. Chinwah testified that the zolpidem level was within the lethal level of 1.1 to 3.2. Dr. Chinwah believed that zolpidem caused or contributed to Elbert's death.
The Department of Coroner's autopsy report ascribed Elbert's death to "multiple drugs toxicity."
The existence of this evidence created a triable issue of fact as to the only issue raised by the summary judgment motion, the cause of Elbert's death. This triable issue of fact requires reversal of the summary judgment.
We caution that our decision is limited to the grounds of the summary judgment motion, the trial court's ruling, and the issues raised on appeal. We express no opinion as to other issues, such as duty, breach, and superseding causation, which may be present in this case.
DISPOSITION
The judgment is reversed. Costs on appeal are awarded to plaintiff Dorota S. Elbert.
We concur:
KLEIN, P. J.
ALDRICH, J.