When An Autopsy Doesn't Tell The Whole Story

This article was originally published by Deceleration

Last summer, Jessica Witzel collapsed, convulsed, and died in the unshaded driveway of a San Antonio gas station during one of the hottest days of 2024, itself the hottest year on record in San Antonio. Her death was reported by area media at the time, based on the accounts of first responders, as the likely consequence of the heat dome that blanketed much of the state under excessive heat warnings all that week. Shortly after her death on August 22, scene investigators recorded an ambient temperature of 106 Fahrenheit and 30 percent humidity—or a heat index of 114F—and logged her body temperature at an unimaginable 126 degrees, according to the autopsy report released to Deceleration by public records request.

The day before she died, San Antonio Police Department encountered Witzel, who had been living unhoused for 18 months at that point, after a homeowner called to report seeing her on their property “attempting to drink water from an outdoor water spigot.” She’d been sick, Witzel told officers, according to SAPD records included in the autopsy report; she’d “been dealing with a fever.”

For Dr. Christina VandePol, a former coroner who researches and writes about death investigation and climate-related mortality, it was as clear a case of heat-related death as they come. “I’ve never heard of a body temperature that high, including in a deceased person,” VandePol said after reviewing Witzel’s autopsy report.

“I can’t imagine a situation more obvious with the ambient temp being that high, her body temp being that high, her symptoms consistent with heat stroke.”

Witzel’s family was therefore shocked when, three months later, they received the official cause and manner of death from the Bexar County Medical Examiner’s Office (MEO): methamphetamine toxicity. Witzel’s blood did contain low levels of methamphetamines, which VandePol described as “slightly above therapeutic but below toxic level,” according to a lab reference guide she shared. A syringe cartridge without needle or plunger was also later found in Witzel’s hoodie. But the autopsy report also noted that Witzel’s mental health history included ADHD, and one prescription ADHD medication (Desoxyn) shows up as methamphetamines on toxicology screens. Without more detailed knowledge of Witzel’s medical history, “there’s no way to differentiate prescribed vs illicit methamphetamines,” according to VandePol.

But the source of the substances found in Witzel’s body is ultimately less important than what the Bexar County MEO neglected to record. While their conclusions narratively acknowledged both the elevated temperature at time of death and the autopsy findings of underlying cardiovascular disease, Assistant and Chief Medical Examiners Breanne N. Vergonet and D. Kimberly Molina ultimately declined to list these as contributing factors in determining Witzel’s official cause and manner of death. Nor did they indicate that San Antonio had been under an excessive heat advisory for several days at the time of Witzel’s death, as the National Association of Medical Examiners has recommended as best practice in certifying disaster-related deaths, including heat waves. 

“Although the decedent was outside during elevated ambient temperatures,” wrote Vergonet and Molina, “the role the environmental exposure may or may not have played in the death cannot be definitely determined, especially in the setting of methamphetamine use.”

Deceleration reached out to Bexar County to clarify these conclusions, but was told by Deputy Public Information Officer Isaac Neri that “it is the policy of the Bexar County Medical Examiner’s Office not to discuss specific cases.”

“They’re trying to make it sound like she died from drugs,” said Witzel’s sister Jemmy Coleman. “My sister had a 126-degree fever. And they ruled her as dying from meth.”

The MEO’s conclusions mirror those in a similar death documented extensively by Deceleration. During August of 2023, Albert Garcia, also unhoused and multiply disabled, died after weeks living unsheltered beneath a highway offramp during San Antonio’s hottest summer on record.

In the days after his death, Deceleration recorded ambient daytime temperatures at his camp as high as 114F. But because drugs were found in Garcia’s system—methamphetamines and heroin, specifically—the MEO attributed his death to substance use alone, failing to list heat as a contributing factor.

Bexar County PIO Monica Ramos in 2023 confirmed to Deceleration that the medical examiner’s office does not track heat-related deaths, or deaths where heat plays a contributing role; it only tracks deaths directly caused by heat. In 2023, Ramos reported to the Texas Tribune 12 deaths from hyperthermia that year, and did not respond to Deceleration’s query as to the source of this data. But when asked if Bexar County’s methods for tracking heat-related deaths remains the same, Deputy PIO Isaac Neri confirmed: “the County does not track deaths when heat is a contributing factor.”

That’s a problem, for a number of reasons.

First: We know that heat-related mortality is increasing. Days after Witzel’s death, national media reported a new study finding a 117 percent increase in heat-related deaths from 1999 to 2023. As acknowledged by Dr. Jeffrey Howard, a UTSA professor of public health who co-authored the study, even this trend is based on an undercount, given the failure of many localities—including Bexar County—to collect data on heat-related deaths in a systematic way.

This undercounting is also a problem given what we already know from places that do collect this data about who is most likely to die during extreme heat events: unhoused people. People with schizophrenia or other underlying health conditions. People who use substances, specifically methamphetamines. People exactly like Witzel and Garcia. 

Public health data from Maricopa County, Arizona—the hottest urban center in the United States, which of necessity has become the national standard for tracking heat-related deaths—quantifies the broader patterns Witzel typified. As reported in its 2023 Heat Death Report, the largest proportion of the 645 heat deaths for 2023—nearly half—were of unhoused people. Nearly two-thirds of all heat-related deaths involved substance use; of those, three-quarters involved methamphetamines or amphetamines specifically. And a study of the 2021 heatwave in the Pacific Northwest also revealed that people with schizophrenia are three times more likely to die during extreme heat events, the highest risk out of 26 chronic conditions reviewed. As described in one case study from Arizona profiled in the Washington Post, schizophrenia is “the most dangerous preexisting condition in a rapidly warming world.”

Given that stimulants alone impair the body’s thermoregulatory system, methamphetamines, whether illicit or prescribed, have become a well-known risk factor in heat-related deaths across the U.S., according to recent reporting in Newsweek, which also noted that this “spike in meth-related heat incidents coincides with climate change.”

Melanie Rouse, Coroner for Clarke County, Nevada—after Maricopa, the second hottest urban center in the United States—echoed these observations in an interview with Deceleration. “If you take heat out as a factor,” she said, “and you’re just looking at methamphetamine deaths alone, there are significantly more of them that occur during summer months when we are in high heat.”

But especially where substances or other underlying conditions are also involved, how is it possible to determine when a death is heat-related? An interview from last summer between Dr. Jeffrey Johnston, chief medical examiner of Maricopa County, and Phoenix’s local NPR affiliate helps clarify:  

[NPR]: [I[n terms of how these things are counted, … if we’re looking at 640-something deaths from last year [in Maricopa] that are associated [with] heat, if somebody overdoses on fentanyl or methamphetamine and then is outside, is that ruled a heat-associated death?

JOHNSTON: Yeah. So we would certify that as heat related. And it would depend really on … our forensic pathologist looking at all the data to decide, is it primarily the drugs that are at play and the heat just contributes to it? Or is it the other way around, where the heat is really the new thing that is mainly at play and the fentanyl or the methamphetamine intoxication that’s contributory?

In other words, there is no outdoor death from methamphetamines during a known extreme heat event where that heat is not at least a contributing factor—going by best practices, anyway.

The week Witzel died, the heat dome over Texas made national news. The day before Witzel died, the day she entered a neighbor’s yard to drink water, was the 4th hottest temperature ever recorded in San Antonio; Deceleration recorded downtown temps far in excess of even the airport’s official 108 degrees. Witzel died the following day, during the hottest part of the third consecutive day of that year’s hottest temperatures.

Knowing the time and resource pressures on medical examiners around the country, VandePol wondered “if it [methamphetamine toxicity] was just the easiest thing to put down. Because it’s a very complicated medical picture. Hyperthermia was definitely a contributing or primary factor. Not just from environmental exposure, but from a combination of things. She’s got preexisting conditions. Then she’s on medication that raises temps”—Benadryl and topiramate, used as an off-label medication for schizophrenia, in addition to the methamphetamines. “And then she’s sick, she has a fever. Then on top of that you have the environmental [factors].”  

“I’m not a forensic pathologist, I’m a physician and former coroner,” VandePol continued. “But I would say it’s just as likely you could point to heat stroke as primary and methamphetamines as contributing as the other way around. But to only put the methamphetamines, which was not that impressive [in terms of level], is not the complete picture.”

Witzel’s sister Coleman is far less circumspect in her take on the report’s characterization of events.

“It’s a fucking lie,” she said.

Telling the truth—providing the complete picture—would mean collecting data on heat mortality in a systematic way, as Clark County Coroner Melanie Rouse instituted when she transferred from Phoenix to Las Vegas. “I had some wonderful mentors in Maricopa County,” she told Deceleration, “and we were able to adopt some of those practices here and utilize standards that had been developed in an office that was already doing a good job of tracking that information. … We now have a robust approach to heat fatalities.” 

A large portion of that approach involves an investigative process that actively looks for how heat may have played a contributing role—looking for “conditions that make people more susceptible to succumbing to heat” and “drugs that cause you to become more susceptible to succumbing to heat illness. We look at intrinsic factors—age, body mass ratio, whether or not somebody has had physical exertion prior to their death, what kind of clothing they’re wearing. Are they well hydrated? Are they able to get access to become hydrated? All of those things have to be factored in when we’re determining whether or not a death is related to or accelerated by the exposure.”

Much of Clarke County’s approach also turns on standardizing how heat-related data is recorded, especially on death certificates, so that public health patterns can be more easily and accurately tracked.

“We developed keywords to utilize in these cases, so that we can better pull the data from our system to provide that information back to the community,” Rouse said. “We developed standards where we are placing that information on the death certificates—whether [heat] is a primary cause, a secondary cause, or a contributing condition.”

Making the contributory role of heat visible in these ways in turn has led to better public health policy, proactively centered on prevention within communities known to be at greatest risk of dying from extreme heat. On the basis of more standardized data collection, Clarke County has launched “programs like water stations, cooling stations for individuals that are unhoused, getting information out to the community—because sometimes these are challenging communities to outreach to.”

It’s a point former coroner VandePol makes often.

“If we don’t know the extent of a problem, we can’t or won’t do much to fix it,” VandePol writes. “That’s what’s going on with heat-related mortality. Until we know how many people are dying of heat exposure and who they are, most government officials and policymakers can and will ignore the existential danger of extreme heat.”

Deceleration is a nonprofit online journal of environmental justice. Sign up for their Deceleration In Depth newsletter.