Tarrant doubles down on sickle cell cause of jail inmate’s death. Experts call it a lie.

Tarrant County has amended its autopsy report for jail inmate Robert Miller to back its findings that his 2019 in-custody death was a result of overexertion leading to a sickle cell crisis, which remains in contradiction to what outside experts have told the Star-Telegram.

Miller, 38, died after he was pepper sprayed three times at close range during his intake and did not receive medical attention when he told a nurse he could not breathe, a Star-Telegram investigation reported last fall. Richard Fries, a county pathologist, ruled in 2020 that Miller’s death was “natural” as a result of a sickle cell crisis.

The amended autopsy report, dated Jan. 23 and released Tuesday, reclassified Miller’s manner of death from “natural” to “undetermined.” The cause is still listed as sickle cell crisis.

Tarrant County officials released the updated autopsy along with communication from the Mayo Clinic Laboratories, which they asked in November 2022 to test Miller’s blood samples for evidence of sickle cell disease.

Two hematologists who study the disease reviewed the documents for the Star-Telegram. Both reaffirmed what they and other experts have previously said: Miller could not have died from sickle cell crisis, which can only occur in people with sickle cell disease.

“I think they are falsely making the association between sickle cell trait and sickle cell disease,” said Dr. Rakhi Naik, an associate professor at the Johns Hopkins School of Medicine.

Sickle cell trait and sickle cell disease are not the same thing. People with one sickle cell gene and one normal gene have the trait, like Miller. To be diagnosed with sickle cell disease, which is the umbrella terms for a group of different blood disorders, a person must inherit two sickle cell traits.

It’s clear that Miller had the trait and the trait alone, Naik said, both because of the testing done at the Mayo Clinic and because his spleen was intact at his time of death. Sickle cell disease frequently causes damage to the spleen.

Naik’s own research was cited in the Mayo Clinic’s report, which referenced her study on the long term effects that sickle cell disease can have on the kidney.

Naik also noted that two types of bacteria were found in Miller’s blood samples in the Mayo Clinic’s report.

“I’m a little surprised that they didn’t consider whether that contributed to his cause of death,” Naik said. If the infections developed before Miller’s death, they could have caused sepsis throughout his body.

“It does seem like he died of shock of some underlying cause, but sickle cell trait doesn’t explain the findings,” Naik said. Sepsis, on the other hand, could have caused or contributed to shock.

It appears that the Mayo Clinic had initially planned to perform a hemoglobin electropheresis, the gold standard test used to diagnose sickle cell trait or disease. But the blood sample sent to Mayo Clinic were apparently too “degraded” for this type of testing, according to the clinic’s report, and so they did DNA testing instead.

Dr. Hannah Lichtsinn, a hematologist in Minnesota who also reviewed the county’s documents, said she believes county officials lied when they said in an April statement that the Mayo Clinic had confirmed sickle cell crisis as Miller’s cause of death.

“The documentation from Mayo said absolutely nothing about whether he had a sickle cell crisis,” Lichtsinn said.

Did exertion contribute to death?

The county’s amended autopsy report makes an argument that Miller’s death may have been from an extremely rare circumstance when exertion can cause death in someone with the trait. The autopsy report cites examples of NFL and college football players and military recruits at boot camp.

Miller, who was living in a camp, resisted officers during his arrest on old misdemeanor warrants and his intake at jail. The amended autopsy report adds more descriptions of Miller’s actions that weren’t in the 2020 original report, including that he was “reported to have struggled with officers during which he lifted two officers on him off the ground.”

“Because officers were physically engaged with Mr. Miller in the last encounter in which he exerted himself and it is not feasible to determine which episode of exertion or if in fact the combination of the events resulted in sufficient exertion to initiate the process that resulted in his death, the manner of death in this case is best reclassified as ‘Undetermined,’” Fries wrote in the 18-page report. The original autopsy report was 11 pages.

Amended autopsy changes

The amended autopsy said sickle crisis associated with sickle cell trait, though very rare, is well-documented and increasingly reported in medical literature. The medical examiner cites 41 sources, most of them more than a decade old — and about a dozen studies that are more than 20 years old. The report says sickle trait was a leading cause of death among high school and college athletes and military recruits.

“The symptoms begin following intense exertion that can be as short as a few minutes,” the medical examiner wrote.

The amended report’s other added details include Miller kicking the door of a patrol car so hard he knocked it out of alignment, pounding a window of a holding room, and struggling with two officers who were on top of him after he became combative.

Then officers pepper-sprayed him three times, according to the report.

The report suggests this exertion combined with the summer heat, his poor conditioning and the fact that he was likely dehydrated as a result of his homelessness contributed to the crisis.

The studies cited by the county involved people under very extreme circumstances, Naik said, and aren’t generally applicable outside of those circumstances. The research in question looks at military recruits and athletes, who were undergoing intense training regiments in the heat, with few breaks and no hydration, Naik said.

Furthermore, the “sudden death” experienced in that research is actually preceded by symptoms of muscle breakdown, Naik said.

“It is not just a sudden collapse,” Naik said. “There are actual symptoms before that happens.”

Fries, the county pathologist, misstates the cause of death that occurs in these extreme circumstances, the hematologists said.

For example, Fries’ report points to the case of Dale Lloyd II, a freshman football player at Rice University who died in 2006, a day after he collapsed during a workout. But Lloyd, who did have the sickle cell trait, did not die of a sickle cell crisis, as Fries imples. He died from rhabdomyolysis, a rare medical condition that can be more likely in people with the trait, Naik said. When people with the trait die from rhabdomyolysis, they are not experiencing a sickle cell crisis.

Lichtsinn said there was no evidence in the county’s documents that Miller died from rhabdomyolysis, the cause of death that Fries incorrectly used synonymously with sickle cell crisis in his report. Rhabdomyolysis causes extreme muscle pain, and typically doesn’t cause immediate death. Lichtsinn noted that Miller never complained of muscle pain, but did report difficulty breathing.

“In this revised autopsy, there is not equal weight given to various potential causes of death,” Lichtsinn said.

The other major flaw Naik noted in the county’s autopsy was that it attributed Miller’s anemia to the fact that he had sickle trait. But Naik said Anemia is not associated with sickle cell trait, only with the disease.

“We would have to attribute the anemia to something else,” she said. “And the question is, what is something else? It’s just a little bit of strange reasoning.”

Third-party review never happened

The Star-Telegram’s October investigation prompted county to contract with Bloomington, Illinois-based medical examiner J. Scott Denton to review of Miller’s autopsy. That autopsy never happened despite Tarrant County medical examiner Kendall Crowns’ promises to overnight materials and extend Denton’s contract, which ended Feb. 28.

County leaders justified not doing the third-party review because they had sent Miller’s blood samples to Mayo Clinic, which had confirmed Miller had sickle cell trait.

Cells can sickle after death when the body loses oxygen.

One of those experts, pathology chair Robert Mitchell at Howard University, said Miller’s death should be attributed to what caused his oxygen level to drop and cells to sickle in the first place — the pepper spray.

Tarrant County on Monday said it would seek an attorney general’s opinion on the Star-Telegram’s request for Miller’s Mayo Clinic test results. It released the documents on Tuesday.

County officials have consistently referred back to Miller’s widow’s wrongful death lawsuit against the Tarrant County Sheriff’s Office as a reason to not release information on the case.

“While there has been a public demand for the release of these documents, Tarrant County is a party in an ongoing lawsuit concerning Mr. Miller’s death,” County Administrator G.K. Maenius wrote in a Tuesday press release. “The County has worked on striking a balance between the public’s desire for information and the needs of the continuing litigation.”

County commissioners respond

In a statement Tuesday evening, commissioner Alisa Simmons said she doesn’t think Miller died from a sickle cell crisis alone — there had to have been some sort of triggering event, she wrote.

“Something out of the ordinary occurred which caused the crisis and facilitated the death,” Simmons wrote. “In Mr. Miller’s case, what was the precipitating factor? Until and unless we are able to answer that question, we cannot claim his death to be a natural occurrence.”

Commissioner Gary Fickes said sarcastically he didn’t know Simmons had a medical degree but did not give further comment.

Commissioner Manny Ramirez said he wanted the county to release every document it has regarding the case, but understands why officials haven’t given out information due to pending litigation.

Commissioner Roy Charles Brooks did not immediately return a phone call for comment.

Representatives for County Judge Tim O’Hare could not immediately be reached for comment late Tuesday.

This is a developing story. Check back for updates.