Nebanda death probe: Govt analyst gives his account

On December 28, 2014, Sunday Monitor, under the headline “Fresh questions over Nebanda death’, made several allegations regarding the death of former Butaleja District Woman MP Cerinah Nebanda.

I was involved in the forensic investigations into the cause of death of the former legislator, and I do not think the version of events as ran by Sunday Monitor is consistent with what exactly transpired. In the case of Nebanda, I led the team of scientists from the Government Analytical Laboratories (GAL) that lifted samples of exhibits collected from the scene.

I later accompanied all the samples, including those collected from the post-mortem examination, that were taken for tests both in the UK and Israel. I brought back the results.

The post-mortem
Where foul play is suspected in a case of death, a post-mortem is formally requisitioned by the police in writing, and any subsequent forensic investigation is undertaken as instructed by the pathologist.

In carrying out the post-mortem, the pathologist may recommend further histological and toxicological tests, in addition to the observations made during the post-mortem. And that is where I come in.

I attended meetings in which the police, some members of the Parliamentary Commission and senior management of Mulago hospital were present. The discussion was about the handling of the samples collected from the post-mortem.

The position of the police, which I agreed with, was that GAL takes the lead in carrying out further tests, and any other party interested in carrying out independent tests could only do so under the supervision of GAL. That was not a new position: it is standard practice, with a good reason.

Samples of tissues and fluids collected from bodies during post-mortem are usually in a fairly delicate state, and they must be maintained under specific conditions, a variation of which would mean they deteriorate (rot) to the extent that they are no longer useful.

At GAL, we have the requisite equipment and chemicals to maintain, store and transport such samples, in stable condition, up to the point required for further tests.

An individual, however experienced, might not be able to meet the requirements, both in equipment and conditions, necessary to deliver a test sample in a manner that is scientifically acceptable for further tests. That was the argument of the police, to which I also subscribed.

To the best of my understanding, Dr Sylvester Onzivua, who was commissioned by some Members of Parliament to carry out independent tests, could not guarantee that he was in a position to meet these basic standards.
In fact, after he was arrested by police at Entebbe airport, and the samples in his possession brought to GAL, we observed that they had been packed in a school bag, without any refrigeration or preservation and, indeed, had started rotting away, and could not have been useful.

The samples of tissues and fluids collected from Nebanda were delivered to me at GAL offices by detective Charles Aluma, escorted by the Mbarara Municipality MP, Dr Medard Bitekyerezo, and others.
At that time, our equipment at GAL was due for service and could not carry out the required tests.

I, therefore, formally advised government that, given the apparent urgency of the case and the ensuing public interest, the samples should be split and taken to separate forensic laboratories abroad.

The government agreed, and we settled for the UK and Israel. I was tasked, together with Dr Moses Byaruhanga, to accompany the samples, and return with the results.

Both labs in the UK and Israel were unanimous in their findings.

It is for this reason that, combined with the observations made during the post-mortem, Prof Henry Wabinga, the lead pathologist, concluded that the cause of Nebanda’s death was “multiple organ failure due to a combined effect of alcohol and drug toxicity”.

In other words, Nebanda’s vital organs collapsed, because of a lethal mix of alcohol and drugs, leading to her death. Now, the entire process and resultant conclusion was challenged by Prof Kakonge, who appeared in court as a defence witness.
Notwithstanding the fact that Prof Kakonge offered the same opinion in court, which opinion was rejected after scrutiny, I will still respond to the assertions he repeated in the Sunday Monitor.

Prof Kakonge’s net position, according to Sunday Monitor, was that the sum total of observed and tested effects could not have caused a lethal dose of medical morphine in Nebanda. Prof Kakonge says Nebanda could not have died of a drug overdose.

I find that position surprising, if not misleading. I am confident Prof Kakonge is aware that death can occur rapidly in some individuals even after taking a ‘normal dose’ of drugs.
This is because of the fact that individuals react differently to ingestion of same substances, so quantitative analysis alone, in a case like Nebanda’s, would not be sufficient to discount the possibility that it could have happened.

It would have helped had the eminent biochemist, Prof Kakonge, guided the author of the story on idiosyncrasy (individual response to drug consumption), or synergistic effects (drug interaction) of alcohol, especially when taken in abuse of subscripted dosage.

Nevertheless, in cases of combined drug toxicity, death may indeed occur outside, or even below, normal toxic ranges, especially when multiple drugs are consumed together, or mixed with alcohol.

The pathologist therefore must interrogate the circumstances, and also rely on forensic investigations as well, to arrive at the cause of death. From my observation, that is exactly what lead pathologist, Prof Wabinga, did.

In the two reports from the UK and Israel, to which Prof Kakonge had access as a defence witness, it was found that:
1. The ante-mortem urine (obtained before Cerinah Nebanda died) contained a cocktail of drugs including morphine, cocaine and their breakdown products (Cocaethylene, 6-monoacetylmorphine, among others). These two breakdown products mentioned are very specific to consumption of cocaine with alcohol in the first instance, and consumption of heroin in the letter. I am sure Prof Kakonge knows this.

2. The ratio of free (unmetabolised morphine) to total morphine (free and metabolised morphine) was determined to be 0.19. If one were to die from “a lethal dose of medical morphine”, this ratio would be greater than 1, because there would be more unmetabolised morphine in the body; which would have been instantly lethal, thus not availing time for the body to metabolise it. Therefore, the argument of “a lethal dose of medical morphine” is not supported by the quantitative toxicology results.

3. Other substances like chloroquine (anti-malarial now out of use), dextromethorphan (cough suppressant), among others, that were found in the urine are commonly added to street drugs as boosters or to mitigate side effects thereof.

Prof Kakonge faults the choice of tissue and fluid samples we took. I think he is mistaken. As a general rule, the following applies:
1. Femoral blood (blood from the thigh) is the most suitable for toxicological analysis. Blood from the heart is discouraged (although sometimes used) because of the concept of post-mortem redistribution/diffusion (leakage of substances into the blood of the heart).

2. Femoral blood alongside other specimens such as stomach contents, liver and urine are acquired at post-mortem. However, the highest concentrations of drug and their metabolites are usually found in blood.

3. There are many other parts or body fluids that can be taken during post-mortem including; hair, vitreous humor, bile, skin, nails, etc. However, blood remains the most cardinal toxicology specimen with regard to toxicological analysis especially in investigating sudden death.

Hair, nail and bone are usually considered when investigating long-term exposure or in specimen obtained after exhumation.

From a purely scientific perspective, I am convinced that Cerinah Nebanda died from the ingestion of more alcohol and narcotic drugs than her body could safely handle. I know that for a fact because I personally handled the forensic investigation.

The writer is a senior government analyst at the Government Analytical Laboratories.

FACTS ON THE TWO REPORTS

1. The UK laboratory analysed the urine specimen using a screening technique for opiates (morphine is an opiate) with a cut-off of 300µg/L and reported “opiates positive”.

The Israel laboratory chose to quantify morphine in the urine but in both instances, morphine being an opiate was prominently present in the urine.

2. The UK laboratory analysed the urine specimen using a screening technique for cocaine with a cut-off of 300µg/L and reported “cocaine positive”, and not traces as the Sunday Monitor states. This is significant.

3. The UK laboratory employed a very sensitive technique to determine qualitatively “traces of cocaine” in the wine. This indeed is consistent with someone sniffing cocaine and taking a drink. This would lead to trace amounts being transferred to the drink.

4. The Israel report makes no mention of cocaine in the drink but mentions gamma-hydroxybutyric acid (GHB) and its precursor gamma-butyrolactone (GBL) in the urine.

Although GHB is a date-rape drug, it is also commonly present (with its precursor GBL) in beverages derived from fermentation of white and particularly red grapes. This finding therefore confirms that the deceased consumed wine.

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