Irini Scordi-Bello - Cross

MR. ALESSI: May I, your honor?

MR. ALESSI: We have not had the pleasure of meeting. So, good morning, Dr. Scordi-Bello.

MR. ALESSI: With regard to cause of death as opposed to manner of death, is it correct that a forensic pathologist is tasked with determining that cause of death — that includes contributing factors, injuries, and circumstances regarding the medical legal death investigation? Is that a fair statement?

MR. ALESSI: And I'm using the term medical legal. Is that a term that you're familiar with?

MR. ALESSI: And is it correct that medical legal means — particularly for medical examiners — that there's a medical aspect to the investigation that you perform, and there's also a legal aspect or a law enforcement aspect to it. Is that correct?

MR. ALESSI: And that's a little different from what physicians usually do, right? Because isn't it the ordinary course that it's mostly just medical, but medical examiners by statute and law need to have both of those prongs taken into consideration. Do I have that right?

MR. ALESSI: So in other words, the forensic pathologist — which you've indicated you are — is tasked with determining the cause of death, which answers the question as to why — in more layman's terms — why did the individual's body stop functioning at a particular time. Correct?

MR. ALESSI: So more broadly, the cause of death is generally defined as the disease or the injury that resulted in the death of a person. Correct?

MR. ALESSI: So let's now, if we could please, move to the manner of death. And I'd like to summarize. I know you covered it on direct, but I want to put it in a slightly different context, and hopefully I'll get it right. So medical examiners, as you've stated, are also tasked with — if they can — determining the manner of death, or the circumstances under which the death occurred. Correct.

MR. ALESSI: So manner can and does involve the circumstances under which the death occurred.

MR. ALESSI: And that causes — the medical examiner — to go beyond just medical analysis. You take into consideration other factors, which we'll get to. Is that correct?

MR. ALESSI: So you talked about — and I'm just going to go through them quickly, but if you could just check me on this — the five main categories of manner of death. So you talked about natural causes, correct?

MR. ALESSI: You talked about accident.

MR. ALESSI: You talked about suicide.

MR. ALESSI: You talked about homicide.

MR. ALESSI: And then the last category, undetermined. Do I have that correct?

MR. ALESSI: So what I'd like to do is to focus on the undetermined category. And my understanding is, doctor, that that's where you landed — that's where you concluded — with regard to manner of death of Mr. O'Keefe. Correct.

MR. ALESSI: So undetermined is a term that is used, and that you use. And does that mean that when the information pointing to one manner is not more compelling than other reasonable possibilities, or the death investigation lacks sufficient information to opine on a manner of death at the time of death the certificate is signed — is that generally correct?

MR. ALESSI: So, as we've talked about, I'm just trying to follow — or just develop some logic — and see if this is in agreement with you: that as a medical examiner, you're specifically tasked with conducting that medical legal investigation. And what we've just talked about is a bit of the method of analysis that you go through for that. Correct.

MR. ALESSI: Yes. So, is it correct that there are four general components to a forensic pathologist death investigation? Is scene investigation one of the components?

MR. ALESSI: Excellent. So scene investigation in the state of Massachusetts is not within your domain in the Office of the Medical Examiner. That is the domain of the district attorney and law enforcement. Correct.

MR. ALESSI: How about another aspect? Forensic autopsy and laboratory testing — that's within your domain. Correct.

MR. ALESSI: And how about police reports and witness statements?

MR. ALESSI: Do you consider information nonetheless from police reports and witness statements in your analysis?

MR. ALESSI: And do you also consider — even though it's not within your jurisdiction in Massachusetts — do you also consider information about scene investigation?

MR. ALESSI: So it's correct then that you consider — whether it's within your jurisdiction or not — you consider scene investigation and police reports and witness statements. Correct?

MR. ALESSI: And then forensic autopsy and laboratory testing is right within your jurisdiction, and therefore of course you consider that. And then lastly, medical history and hospital records — am I correct that that's something within your jurisdiction and that you consider in performing your forensic pathologist death investigation?

MR. ALESSI: So now let's move on to the application of those principles. So in order to conduct a proper medical legal investigation, the medical examiner has to have certain qualities, if you will. Is one of them being well grounded in general medical knowledge?

MR. ALESSI: Is another appropriate training and experience in forensic pathology?

MR. ALESSI: In other words, you wouldn't want a specialist — for example, in cardiology, without anything more — to be conducting a death investigation. Is that correct?

MR. ALESSI: Correct. Right. Would you want a neurologist to conduct a death investigation?

MR. ALESSI: No. I — every physician has their specialty and their training, and forensic pathologists are trained to perform autopsies, and cardiac surgeons are trained to perform cardiac surgery. Would you want a neurosurgeon to be conducting a death investigation — to be performing an autopsy?

MR. ALESSI: So you wouldn't want a neurosurgeon to perform an autopsy?

MR. ALESSI: Because you don't believe they're qualified to do so?

MR. ALESSI: Going back into the many qualities and attributes of a medical examiner, they also have to have the ability to form opinions based upon all the available information, using the scientific method along with sound reasoning. Is that a fair statement?

MR. ALESSI: And you're familiar with the term scientific method?

MR. ALESSI: And is it fair to say that the scientific method generally is a systematic pursuit of knowledge that involves recognition and definition of a problem? Is that fair?

MR. ALESSI: Is it also involved — does it also involve the collection of data through observation and experimentation where appropriate?

MR. ALESSI: Does the scientific method also include the analysis of data?

MR. ALESSI: Does the scientific method also include the formulation, evaluation, and testing of hypotheses?

MR. ALESSI: And does it also, where possible, include the selection of a final hypothesis after considering other hypotheses?

MR. ALESSI: So what we've just discussed is a fair explication — a fair explanation of the scientific method.

MR. ALESSI: And the scientific method is part of the autopsy and forensic pathology analysis.

MR. ALESSI: Now, applying one concept — that medical legal concept we talked about — just holding for a moment if you could the medical, and going to the legal, if you will: law enforcement, that you said in Massachusetts is not under your jurisdiction, but nonetheless you consider information arising from it.

MR. ALESSI: Are you familiar with a person named Michael Proctor? Is that name familiar to you?

MR. ALESSI: And at one time, Michael Proctor was a trooper.

MR. ALESSI: And so, did former trooper Proctor inform you of the working law enforcement theory at the time of the investigation of this matter — namely, his working theory, a collision of a motor vehicle with a pedestrian? Did he inform you of that?

MR. ALESSI: He informed your office.

MR. ALESSI: And is it fair to say that he informed your office — or provided that information to your office — in or about February of 2022?

MR. ALESSI: The autopsy was January 31st. Your honor, if I could — with your permission — please publish a photograph which your honor has and the parties have stipulated, or that is already in evidence. And this is the one. I approach your honor.

MR. ALESSI: Thank you. May I?

MR. ALESSI: Thank you. Dr. Scordi-Bello, if I could hand that to you, please — you could take a look at it, and when you've had a fair opportunity to look at it, you can just look back up and I'll proceed at that time.

MR. ALESSI: Thank you. What is depicted in that picture?

MR. ALESSI: Very good. If you could just hold that for a moment — and with the court's permission, could I publish that for the jury?

MR. ALESSI: Thank you, Mr. Woll. And if you could please zoom in on the two individuals in that picture. Dr. Scordi-Bello, do you recognize any of the individuals in that picture?

MR. ALESSI: With regard to the person on the right, do you recognize that person?

MR. ALESSI: And you said you recognized the setting, correct?

MR. ALESSI: And if I heard you correctly, you said this is the Cape Cod facility.

MR. ALESSI: Right. So you testified earlier, if I recall correctly, that the autopsy was performed at the Cape Cod facility of the Office of the Chief Medical Examiner.

MR. ALESSI: And you're normally in, as I recall, the Westfield office — an office that covers Western Massachusetts in Westfield, correct? But you were at the Cape Cod facility, as I understand it, because there was a staff shortage and you had to travel down to Cape Cod for this. Is this correct?

MR. ALESSI: So you weren't at your normal home-based sort of facility. This is a facility that you went to for this autopsy, correct?

MR. ALESSI: Yes. And you were covering a staff shortage, and that was the reason you went to Cape Cod.

MR. ALESSI: And what's depicted in this picture are two individuals. For two individuals to be present, is there a protocol that they had to follow to be present for that — like a sign-in or an authorization?

MR. ALESSI: So they have to put a shield number down, correct? You mentioned a shield number.

MR. ALESSI: And does that therefore mean that — even though you don't know who they are — that they are with law enforcement? Are you able to determine that?

MR. ALESSI: So those two individuals were with law enforcement, but you don't know who they are.

MR. ALESSI: Fair. That's fair. That's fair. I'm not going to ask you more questions to probe the memory. We can take that down. And yeah, we are finished with that. If you could hand that to the — Thank you. Now, we were speaking about former trooper Proctor. Do you recall former trooper Proctor sending you a copy of scene photographs and wanting to schedule a phone call with you so that he could explain the status of his investigation? Do you recall that?

MR. ALESSI: And that occurred approximately in March of 2022.

MR. ALESSI: Right. And the method of communication — was that by email, to the best of your recollection?

MR. ALESSI: Now, you've mentioned the 90 days on direct. You just mentioned it now. Is the 90 days a hard and fast rule, or is it just something you aspire to as a matter of good practice?

MR. ALESSI: So, is it possible to go over the 90 days?

MR. ALESSI: So it's possible to go past the 90 days, but — given the considerations you just articulated — there'd have to be a pretty good reason why you'd want to do that, right?

MR. ALESSI: And in this situation, you concluded that you had sufficient information on the medical side and the legal side to come to the conclusions that you needed to come to. Is that fair?

MR. ALESSI: Exactly. So the manner of death is undetermined. And I want to — if I could — pursue that a little bit in a moment. But when you came toward the end of that 90-day period, you had had information from the law enforcement side on their theory of what had happened.

MR. ALESSI: I'll let that one stand. You had performed all of the medical investigation and analysis that you needed to perform. Is that correct?

MR. ALESSI: There wasn't something more that you wanted to do on the medical side. And you had mentioned — to be fair — you had had Dr. Stonebridge involved as well. You had what you needed on that side.

MR. ALESSI: And you therefore concluded on the manner of death that there was not a more compelling or more likely than other reasonable possibilities. Is that fair?

MR. ALESSI: So, in furtherance of that, on April 14th of 2022, you issued a death certificate. Correct?

MR. ALESSI: And please feel free to check your report for any dates or any other particulars as I go through.

MR. ALESSI: Correct. And I would assume that the death certificate was on or around that same day. Thank you. Now, to back up a little bit with regard to the autopsy — as you stated, it was conducted — I just want to do a little bit of a timeline — on January 31st of 2022, correct?

MR. ALESSI: And we discussed that the body of Mr. O'Keefe was presented to the Cape Cod location.

MR. ALESSI: And you also discussed that you brought Dr. Stonebridge to work with you on this matter.

MR. ALESSI: Who asked Dr. Stonebridge to become involved in the matter?

MR. ALESSI: And Dr. Stonebridge is triple board certified. Correct.

MR. ALESSI: She's a forensic pathologist. Correct.

MR. ALESSI: That means she's achieved board certification in forensic pathology like you. Do you know that?

MR. ALESSI: She's board certified in forensic pathology and she is board certified in general pathology. Correct.

MR. ALESSI: And she's board certified in neuropathology. Correct.

MR. ALESSI: Can you briefly describe to the jury what neuropathology is?

MR. ALESSI: Now, you asked her to be involved, as you indicated earlier, correct?

MR. ALESSI: And you determined that she should be involved because there was a brain injury. Correct.

MR. ALESSI: Trauma to the brain. Is it a fair characterization that Dr. Stonebridge is sort of the brains of the brain area of autopsy? Is that fair?

MR. ALESSI: So, with regard to Dr. Stonebridge, would you agree that she's really uniquely qualified in some ways, or how would you describe her qualifications?

MR. ALESSI: Yes.

MR. ALESSI: May I — you're on? Yes. Thank you. Dr. Scordi-Bello, are you aware of a doctor named Azique Wolfe?

MR. ALESSI: Now, I'd like to move on to another category. Based on the information that was presented to you as part of your examination and analysis, is it correct that you presume that because Mr. O'Keefe's body was found in the snow and his body temperature was 80° that he died from hypothermia as one of the causes?

MR. ALESSI: Did you consider whether there may have been other reasons as to why his body reached that temperature of 80°? Sort of applying the scientific method and seeing if there were other reasons other than being out in the snow.

MR. ALESSI: Do you know whether there are other alternative reasons how his body could reach the temperature of 80°?

MR. ALESSI: You're familiar with the medical phrase differential diagnosis, correct?

MR. ALESSI: And a differential diagnosis is a term that's used by doctors to pursue other potential causes of a medical injury. Is that a fair general statement?

MR. ALESSI: So for example, if somebody is having difficulty breathing, a doctor may say, I think it's the heart as their primary hypothesis, but they may want to differentially diagnose and look at the lungs. Is that an example of a differential diagnosis — let's look at the lungs to see if that may be the problem? Is that a good fair example?

MR. ALESSI: So, applying that concept to this situation, did you perform a differential diagnosis as to the cause of the death and question whether there was hypothermia as any cause of the death of the decedent? Did you make that analysis?

MR. ALESSI: So you just used the phrase hypothermic changes. Did I hear that correctly?

MR. ALESSI: Can there be hypothermic changes without a cause of death being hypothermia?

MR. ALESSI: So, you can have signs in the body of hypothermia, but you can also conclude that a cause of death is not from hypothermia. Correct.

MR. ALESSI: So I want to break that down a little bit if I could with you. So you testified on direct, and I think you alluded to it here, that the primary cause — and you used that phraseology on direct — was blunt force injury. Is that correct?

MR. ALESSI: Blunt impact injuries to the head. And that's the primary cause. Right.

MR. ALESSI: And then there's — and I'm not clear on what you referred to on direct as a secondary cause of death — of hypothermia, but you used a little different phrase in some of your answers and I want to make sure I got it right. Hypothermic considerations. Can you repeat what it was?

MR. ALESSI: Hypothermic changes. And we agree that you can have hypothermic changes without a conclusion of hypothermia. Correct.

MR. ALESSI: So you can — I'm sorry. Did you finish?

MR. ALESSI: As you sit here now, with regard to the phraseology you use — consistent with hypothermia, signs of hypothermia — that's what I want to pursue just a little bit. With regard to further information, we got started on this by asking whether you used the concept of differential diagnosis and hypothesis to determine the cause and manner of death. And you said in one of your answers that you relied upon law enforcement information, correct? Is that part of it?

MR. ALESSI: Correct.

MR. ALESSI: And you've brought that up on your direct testimony and earlier in the cross. Is that correct? That you relied upon the investigation of law enforcement?

MR. ALESSI: So now what I'd like to do is to ask you whether, using the concepts of differential diagnosis and scientific method, did you consider whether Mr. O'Keefe could have died somewhere other than where the body was found and been moved and placed in the snow. Did you consider that?

MR. ALESSI: May we approach, your honor?

MR. ALESSI: Thank you. What if any alternative diagnosis did you apply to Mr. O'Keefe?

MR. ALESSI: What alternative scenarios did you look at, if any, for the cause or manner of death of Mr. O'Keefe?

MR. ALESSI: Did anyone provide to you any alternatives as to the finding of the body of Mr. O'Keefe in the snow?

MR. ALESSI: Did you ask for any alternatives to the nature and location of the injury or death of Mr. O'Keefe?

MR. ALESSI: Understood. But my question is, did you ask for any alternatives to the information that was provided to you as regards the location of the injuries? Did anyone provide you any alternatives to where the injuries could have occurred?

MR. ALESSI: Okay. So, I'm going to let the answer stand. So, the answer is no. So, there's no evidence of that. So, next question. So, you talked about the information you had at the time. What time is that?

MR. ALESSI: And when I asked about the time, I'm not — calendar time. Was this January, February, March, April of 2022?

MR. ALESSI: Do you have the ability to amend a death certificate?

MR. ALESSI: And you can amend a certificate if you obtain further information with regard to the circumstances surrounding the death. Is that correct?

MR. ALESSI: In your previous answers, you were talking about the information you had at the time and I'm concluding that the latest that would be is April of 2022. Is that correct?

MR. ALESSI: Have you obtained or been provided with further information — in other words, information after April of 2022 — regarding the cause or manner of death?

MR. ALESSI: Well, what I'm just talking about is any other information that you have received or considered in terms of the analysis with regard to the cause or manner of death?

MR. ALESSI: Here's what I'll do — I'll be a little more specific. What I want to do is to get at the head injury of the decedent. Okay. Is it fair to say that the head injury — you called it — I want to use your phraseology.

MR. ALESSI: So, blunt impact injuries of the head. Is it fair to say that that was a very severe injury?

MR. ALESSI: And would Mr. O'Keefe have been rendered unconscious nearly instantaneously with death following shortly thereafter?

MR. ALESSI: Is it more than possible? Is it probable that that's what would have occurred?

MR. ALESSI: Is it possible he could have been rendered unconscious immediately?

MR. ALESSI: You made your own determination of the cause of death. Correct.

MR. ALESSI: Understood. And what I want to do is to pursue the basis of your determination. So you used the phrase "brain impact injury."

MR. ALESSI: A blunt impact injury. Have I got that correct?

MR. ALESSI: Of head. Right. And that's your conclusion. Correct.

MR. ALESSI: Based upon your conclusion, did you make any determination as to whether the decedent would be able to carry out any purposeful movement after that injury?

MR. ALESSI: Sure. I'm talking about the ability to perhaps manipulate their hands. I don't know. Did you make any determination as to whether they would be able to engage in any cognitive functions, meaning processing things and making decisions?

MR. ALESSI: Did you observe any pattern to the injuries to the head of the decedent?

MR. ALESSI: Your honor, if we could please publish — I'm just going to check to make sure they're in evidence. If we could, your honor, publish exhibit 160 that is in evidence. But before we do, Mr. Woll, I would like to approach your honor and let you know in case there's anything further that needs to be done.

MR. ALESSI: I just wanted to make sure if there was any statement your honor wanted to make. So why don't you come over here — may I, your honor?

MR. ALESSI: Thank you. With your honor's permission, I would like to publish exhibit 160.

MR. ALESSI: Thank you. Dr. Scordi-Bello, if you could please draw your attention to what is depicted on both screens. Pick whatever screen is most convenient for you. And what I want to do is to go over what is depicted there. And I'd like to start with just some basics. What is that white rectangle that is on the photograph?

MR. ALESSI: And what's the purpose of the ruler?

MR. ALESSI: And if you could please draw your further attention to what I will refer to — and you use your own term — but just to start with, the horizontal line that appears to be a laceration. Do you know what I'm referring to?

MR. ALESSI: Right. So it's fair to say that that's a laceration. Correct.

MR. ALESSI: And just so we get all that's depicted on this — you referred to earlier, up above, the red area. Is that an abrasion?

MR. ALESSI: And do you also denote to the left almost like a J-type item going vertically up?

MR. ALESSI: And going up — do you see that?

MR. ALESSI: That's my point. So you didn't make a separate note of what appears to be a J, and it might be easier to see it on the screen over there. It's your conclusion, but is it easier to see there?

MR. ALESSI: And so you didn't make a separate note as to what that was in your report. Correct?

MR. ALESSI: Do you consider that an abrasion or something else?

MR. ALESSI: Do you conclude that that J is different in any manner from the abrasion that you've noted above the laceration?

MR. ALESSI: Fair enough. Would a fall backwards on flat frozen ground produce a circular and not a linear abrasion as depicted here on the back of an injured person's head?

MR. ALESSI: Sure. Assume a fall backwards on flat frozen ground. Would such a fall and impact present that type of pattern, or would it perhaps present something like a starfish in the middle?

MR. ALESSI: My question is more specific, and that is a fall backwards where the person impacts the back of their head on flat frozen ground. Would you expect that type of a laceration from that type of a fall? Not just a general fall backwards, but specifically a fall backwards where the back of the head hits flat frozen ground. Would you expect that?

MR. ALESSI: And under what circumstances could a laceration like that — and the abrasion, all of it together — what circumstances could cause that type from a fall backwards on flat frozen ground?

MR. ALESSI: Are you familiar with the phrase "pattern recognition" in medicine?

MR. ALESSI: And isn't pattern recognition something that requires training with regard to being able to recognize certain patterns and determining what could be causing that pattern?

MR. ALESSI: And just merely recognizing whether there is a pattern takes certain specialty training, et cetera. Correct.

MR. ALESSI: And isn't pattern recognition a principle that you apply in the medical examiner's office?

MR. ALESSI: An example of pattern recognition could be a knife wound. Correct.

MR. ALESSI: Could be a gunshot. Correct.

MR. ALESSI: And there are certain patterns that you see on a decedent that can be consistent with those types of causes of injury. Correct.

MR. ALESSI: Assuming a fall backwards onto frozen ground and there being grass on a lawn, would you expect to see any grass at all in the injury site?

MR. ALESSI: Are you familiar with the height and weight of the decedent generally? And if you need to look at your notes, please do so.

MR. ALESSI: So assuming a fall backwards and an impact on a ground with grass — a person who's 6'1" — there is going to be significant acceleration forces that occur as they're going backwards. Is that correct?

MR. ALESSI: And therefore the more acceleration forces, usually there's a correlation with the force of the impact. Correct.

MR. ALESSI: And in terms of force of impact and assuming grass on the ground, would you believe it's more probable than not that one would then see some grass on the head — [unintelligible] — given what you testified regarding the height of Mr. O'Keefe and assuming the fall backwards and acceleration forces, would you expect to see anything else on the back of his head?

MR. ALESSI: Thank you. So, would you expect to see — is it possible, if that was the manner of the fall, that there should be grass on the head? Is that possible?

MR. ALESSI: Did you consider at all in your evaluation — let me back up. Do you see any evidence of grass in this depiction?

MR. ALESSI: Did you recall ever seeing any evidence of grass when you were performing the autopsy?

MR. ALESSI: Did you consider at all in performing your autopsy whether or not grass should be present given what was reported to you by law enforcement?

MR. ALESSI: Did you make any considerations at all regarding grass in regard to your autopsy report?

MR. ALESSI: And was grass at all even a consideration in your analysis?

MR. ALESSI: So the answer is no to that question. Thank you. Did you have any information regarding the circumstances that you said you look at in trying to determine manner of death as to whether there were any stones or rocks around the scene?

MR. ALESSI: So meaning you didn't have any information. You saw no information that there were any stones or rocks by the scene. Is that correct?

MR. ALESSI: What if any consideration did you make in your assessment of cause and manner of death with regard to stones or rocks?

MR. ALESSI: Did you consider any other possibilities that could cause the type of injuries that are depicted on the screen?

MR. ALESSI: My question is did you consider — not whether there are, but whether you considered them at the time you were performing the autopsy.

MR. ALESSI: Did you put in your notes or your autopsy report any of those considerations? Are they documented?

MR. ALESSI: Now, in terms of differential diagnosis that we talked about, did you determine whether there were any other possible explanations for the injuries to the decedent other than what law enforcement presented to you?

MR. ALESSI: Did you make any notes at all about the considerations you were just speaking about — any other consideration? Any notes whatsoever in any document in your autopsy report?

MR. ALESSI: Did you make any other notes of those considerations in any document that you created for this case at all?

MR. ALESSI: And I don't want you to go into what other people said, but I want you to finish your answer.

MR. ALESSI: Your honor, I'm going into a different category, so I just wanted to alert your honor to it.

MR. ALESSI: Oh, yes.

MR. ALESSI: Defense has nothing, your honor.

MR. ALESSI: Thank you, your honor. Good afternoon, Dr. Scordi-Bello, and welcome back.

MR. ALESSI: I want to move on to a slightly different aspect of the hypothermia discussion. So you've acknowledged previously that hypothermia is a very difficult diagnosis to make. Correct.

MR. ALESSI: And you acknowledged that in your grand jury testimony in this proceeding. Correct. Do you recall that?

MR. ALESSI: And you indicated in that grand jury proceeding generally that diagnosing hypothermia is based on contextual clues. Is that correct?

MR. ALESSI: Right. And the last part — investigative — that's the legal part, sort of the law enforcement contribution. Is that correct that you're referring to?

MR. ALESSI: You diagnosed Mr. O'Keefe with hypothermia based upon certain medical data that you believe you observed in the gastric area and the pancreatic area. Is that correct?

MR. ALESSI: And just for — I think most people will get this just because gastric is sort of synonymous with the stomach — stomach, and then we know the pancreas is a separate organ. And in your autopsy you observed, for example, the lining of both the stomach and the pancreas. Is that correct?

MR. ALESSI: Let's start with the stomach. Did you observe the lining of the stomach as part of your autopsy of Mr. O'Keefe?

MR. ALESSI: We'll get to that. Right. But I just want to talk about the organs and what aspects of the organs first, and then we'll get to that. And with regard to the pancreas, what aspect of the pancreas did you observe?

MR. ALESSI: Correct.

MR. ALESSI: Histopathology. Spell it.

MR. ALESSI: So that histopathology information informed your hypothermia analysis. Is that correct?

MR. ALESSI: So do I have it correct? And let's start with the pancreas — that you noted the pancreas was congested and diffusely hemorrhagic. Do I have that correct? And you feel free to look at your report, please.

MR. ALESSI: Looking at the report of autopsy. It's not numbered pages but it would be four. And you see liver, gallbladder and pancreas is one, and then you go down a couple more and you see digestive system. That's what I'm focusing on.

MR. ALESSI: And the next page is the histopathology.

MR. ALESSI: All right. Are we sort of oriented in the same location?

MR. ALESSI: All right. So let's start with the pancreas. So if you look at the histopathology page, it says endocrine and exocrine pancreatic tissue with vascular congestion and patchy parenchymal — that's P A R E N C H Y M A L — hemorrhage, autolytic changes. Did I read that correctly?

MR. ALESSI: And I want to go at these one at a time. So now I'm going to jump back to the previous page where you discussed the heading liver, gallbladder and pancreas. Do you see that?

MR. ALESSI: And you see the last sentence says the pancreas is congested and diffusely hemorrhagic. You see that?

MR. ALESSI: So now what I'd like to do — and is that what you're rooting in, if you will, the analysis of hypothermia, the determination of hypothermia was made?

MR. ALESSI: Yes. Right. And thank you. I'm going to get to the circumstances, but in sort of the medical legal construct that we were talking about, I want to just start first with the medical, if that's okay with you.

MR. ALESSI: So then let's now move to the organ of the stomach — a synonym, gastric — in terms of your report. So let's go back to the histopathology section. And under that, under pancreas, is stomach, and there's a bulleted one sentence that says gastric tissue with vascular congestion and focal mucosal hemorrhage. Did I read that correctly?

MR. ALESSI: And then let's go back, as we did with the pancreas, for the stomach — go back to the previous page in your report under the heading digestive system, and the second sentence states the gastric mucosa shows focal areas of linear hemorrhages. Did I read that correctly?

MR. ALESSI: So we've got hemorrhage discussion with the pancreas. We've got hemorrhage discussion with the stomach and the gastric area. Your diagnosis of hypothermia was not based just on gastric and pancreatic hemorrhaging alone though, was it?

MR. ALESSI: And you did fairly refer to other circumstances just moments ago in your answer.

MR. ALESSI: And we're going to get to that. So that means that your diagnosis of hypothermia was also informed by the information we discussed earlier that was provided to you by former Trooper Proctor in his investigation. Is that correct?

MR. ALESSI: And one aspect of that information is that Mr. O'Keefe was found in the snow.

MR. ALESSI: So, let's go to the death notification report. Am I generally correct that — I'm sorry. I will — Thank you, your honor. Do you recall the death notification report in this matter?

MR. ALESSI: Do you recall the contents of that death notification report?

MR. ALESSI: Would it be helpful to you if I showed you a document that might refresh your recollection on what that — a document that may refresh?

MR. ALESSI: I did. Thank you, your honor. May I — INAUDIBLE — show? Yes. Yes. Dr. Scordi-Bello, what I'd like to do — you can read anything you want, but I'm just going to reference the section that says circumstances of death. Yes. What I'd like you to do is read it to yourself, not out loud. And then — just that section, up to here — and once you're done, if you could kindly look up and let me know. Dr. Scordi-Bello, did that refresh your recollection with regard to the circumstances of death section of the death notification report?

MR. ALESSI: And could you please state now what your refreshed recollection is on that topic?

MR. ALESSI: Yes. In terms of the differential diagnosis concept that we were talking about before, based upon your refreshed recollection of circumstances of death as discussed in the death notification report — based upon that, did you consider whether Mr. O'Keefe could have been injured and died somewhere other than the front lawn of 34 Fairview?

MR. ALESSI: Let's go to the significance, if any, of hemorrhaging of the two organs we were talking about — the pancreas and the stomach. Is it correct that the hemorrhaging of a pancreas can be caused by many different things?

MR. ALESSI: And to be clear, you found evidence of hemorrhaging of the pancreas of Mr. O'Keefe in the autopsy.

MR. ALESSI: And is it correct that before the grand jury you yourself were evaluating whether the injuries had been sustained in a different environment? Well, let me ask it this way. Do you recall your testimony in the grand jury about hemorrhaging of the pancreas and possibilities of injuries being sustained in different environments? Do you recall that testimony?

MR. ALESSI: Excuse me. Thank you. May I, your honor?

MR. ALESSI: At the grand jury, did you testify as follows? "If the injuries had been sustained in a different environment where the temperature wasn't that low, then there might have been an alternative explanation for those gastric and pancreatic hemorrhages." You recall that?

MR. ALESSI: Hemorrhaging of the pancreas can also be caused by blunt force trauma. Correct?

MR. ALESSI: Hemorrhaging of the pancreas can be caused by CPR — cardiopulmonary resuscitation.

MR. ALESSI: Do you know what a Lucas machine is?

MR. ALESSI: And a Lucas machine is an automated CPR machine.

MR. ALESSI: And it's a rather large device.

MR. ALESSI: It gets strapped down to the chest of someone — so instead of someone having to manually exercise compressions, you put on a Lucas machine that goes over the chest and it automatically does the compressions. Right?

MR. ALESSI: Lucas machines can cause hemorrhaging.

MR. ALESSI: And in fact, wasn't a Lucas machine applied to Mr. O'Keefe?

MR. ALESSI: And wasn't the Lucas machine applied from when the first responders came to the scene, and he was in the ambulance, continually, and through when he was in the hospital?

MR. ALESSI: So when a Lucas machine is used in resuscitation efforts, you'd actually expect to see some hemorrhaging, wouldn't you? Where? In the stomach and in the pancreas. Would you expect to see it there?

MR. ALESSI: Let's talk about — and pick the pancreas first. So you would agree that from the use of a Lucas machine, you would expect some degree of hemorrhaging in the pancreas.

MR. ALESSI: And there was evidence of hemorrhaging in the pancreas of Mr. O'Keefe.

MR. ALESSI: Now let's move to the stomach. Isn't it possible that a Lucas machine could cause hemorrhaging in the stomach?

MR. ALESSI: But do you rule that out?

MR. ALESSI: So your personal experience is you don't believe you've seen that, but you can't rule out that a Lucas machine causes hemorrhaging to the stomach. Is that correct?

MR. ALESSI: Right. I'm not yet at the mucosa of the stomach, which is a subset of the stomach. Right. You're talking about the gastric rugae.

MR. ALESSI: Inner lining. Another name for the inner lining of the stomach is the gastric rugae — r u g a e. Correct?

MR. ALESSI: So I'm just talking about the stomach in general, not a subset of the stomach. Is it possible that a Lucas machine could cause hemorrhaging in the stomach?

MR. ALESSI: Okay. So, you've said that you're aware that Mr. O'Keefe was hooked up to a Lucas machine, correct?

MR. ALESSI: And are you aware of the length of time that Mr. O'Keefe was hooked up to a Lucas machine?

MR. ALESSI: Would 100 compressions per minute be a reasonable number of compressions for a Lucas machine to cause?

MR. ALESSI: So assume 37 minutes of a person hooked up to a Lucas machine and assume 100 compressions per minute. That would result in 3,700 compressions from a Lucas machine. Correct?

MR. ALESSI: Could 3,700 compressions from a Lucas machine explain hemorrhaging in the pancreas?

MR. ALESSI: And that explanation could be why there's hemorrhaging in the pancreas, as opposed to hypothermia causing hemorrhaging in the pancreas. Correct?

MR. ALESSI: Did you consider that at all in your autopsy report? The effect of the Lucas machine — is it written anywhere in your autopsy report?

MR. ALESSI: My question was: does your report state anywhere the words "Lucas machine"?

MR. ALESSI: And you agree that a Lucas machine can cause hemorrhaging to the pancreas?

MR. ALESSI: Including the pancreas. If you see hemorrhaging of the pancreas and you believe that hemorrhaging is a contributor to hypothermic deaths, wouldn't you also expect to see Wischnewski spots?

MR. ALESSI: So the court reporter needs to have a spelling of that. Doctor, can you give us the spelling of that? Would you like to give it?

MR. ALESSI: Thank you.

MR. ALESSI: So can you just tell the jurors what Wischnewski spots or Wischnewski ulcers are?

MR. ALESSI: Is it correct that if someone is believed to die at least in part from hypothermia, that in 90% of cases of death from hypothermia you would find Wischnewski ulcers?

MR. ALESSI: Is it that you're not recalling what the percentage is — the percent of cases for death from hypothermia — where you would expect to find Wischnewski ulcers?

MR. ALESSI: Do you recall? Do you recall?

MR. ALESSI: So you're — yes. Go ahead. There were no Wischnewski ulcers present in Mr. O'Keefe. Is that correct?

MR. ALESSI: Can you point anywhere in your autopsy report where the word Wischnewski appears?

MR. ALESSI: Right. So you didn't use the term Wischnewski and you didn't use the term ulcer — correct — in your report at all?

MR. ALESSI: Do you believe that all hemorrhages in the pancreas are Wischnewski ulcers?

MR. ALESSI: I'm going to start with the pancreas.

MR. ALESSI: Right. So I wanted to clarify that. So now I want to move to the stomach. Okay. Do you believe all hemorrhages in the stomach are Wischnewski ulcers?

MR. ALESSI: Therefore, there can be Wischnewski ulcers and not be hemorrhaging. Correct? Just by logic. And not be hemorrhaging. Correct?

MR. ALESSI: What I'd like to do now — Mr. Woll, that exhibit has been admitted into evidence. What I'd like to do is, with your honor's permission, publish some depictions of first the gastric mucosa, and then — uh, start with that, your honor.

MR. ALESSI: So this is the one that we have not introduced into evidence openly, but it's — sidebar, right? What I'd like to do is — I'll start with the one that is in evidence, which is the gastric mucosa. Okay. Start with that. What number? Um, your honor, it just — okay. So that was the one I was referring to that we did at sidebar, not in open court. Okay. Yes. It's [Exhibit N]. And I'd like to move [Exhibit N] into evidence at this time.

MR. ALESSI: I'm satisfied with that, your honor.

MR. ALESSI: Dr. Scordi-Bello, I'm handing you Exhibit 164 in evidence, and I'm going to, with the court's permission, have it published on screen. So whatever is best for you to look at — the exhibit or the screen — please feel free to look at either one. Mr. Woll, if you could publish 164. Dr. Scordi-Bello, do you recognize 164? Well — you describe what 164 is.

MR. ALESSI: Right. So those are what you just showed — the dark areas, just a few of them — that is what you refer to as hemorrhages. Correct? Wischnewski. Correct? Well, you didn't use the term Wischnewski in your report. Correct? You refer to them as hemorrhages. Correct? Okay. So what I'd like to do now is — may I approach, your honor?

MR. ALESSI: For the chalk exhibit. Your honor, with your honor's permission, may I show Dr. Scordi-Bello the chalk exhibit marked for identification?

MR. ALESSI: Yes.

MR. ALESSI: Okay. Yes. May I hand it to you?

MR. ALESSI: Dr. Scordi-Bello, could you please take what's identified as Exhibit M and see if you can identify what that depicts?

MR. ALESSI: Your honor, can we take a break?

MR. ALESSI: Thank you, your honor. May I reapproach?

MR. ALESSI: Dr. Scordi-Bello, you have in front of you what has been marked for identification as Exhibit MN, and you were discussing that. Do you recognize that document? Can you sort of start over to reorient?

MR. ALESSI: And what is it?

MR. ALESSI: And does that exhibit fairly and accurately depict a stomach with what you have referred to as multiple hemorrhages?

MR. ALESSI: I offer that into evidence.

MR. ALESSI: I believe — as I — I'll — you know what, if I can use it as a publication. Yeah, that's what I'll do, your honor.

MR. ALESSI: Thank you.

MR. ALESSI: And again, I'll leave this hard copy with the court reporter and we'll use the screen. Oh, so it's not in evidence.

MR. ALESSI: It's marked for identification.

MR. ALESSI: Marked for identification, and we are with Mr. Woll. Dr. Scordi-Bello, is that the depiction that you were just describing at your witness stand?

MR. ALESSI: And could you please, with the laser pointer, state what you see in this depiction?

MR. ALESSI: And to be clear, this is not the stomach of Mr. O'Keefe. This is a medical reference depiction — a generic, or some other depiction other than Mr. O'Keefe's stomach. Correct?

MR. ALESSI: If we could, with your honor's permission, Mr. Woll, put side by side this chalk with what is in evidence as the actual gastric mucosa of Mr. O'Keefe.

MR. ALESSI: Could we, with your honor's permission, publish simply Mr. O'Keefe's gastric mucosa?

MR. ALESSI: Isn't it correct, Dr. Scordi-Bello, that there are much fewer dark spots in this depiction of the gastric mucosa than there were in the chalk that we just displayed — in other words, that green depiction of what I'll just refer to as a generic stomach. Is that correct?

MR. ALESSI: So you can take that down, Mr. Woll. Isn't it correct that for hypothermia and the presence of Wischnewski's ulcers or spots, that you have to have a predominance of the stomach covered by the spots for them to be Wischnewski ulcers?

MR. ALESSI: In hypothermia, particularly death from hypothermia, wouldn't you expect to see a predominance of those ulcers, meaning they take up most of the stomach lining? Isn't that what you would expect to see?

MR. ALESSI: But isn't the majority of the cases that you have seen where someone has actually died from hypothermia that the ulcers predominate — take up greater than 50% of the stomach?

MR. ALESSI: And what percentage of the gastric mucosa of Mr. O'Keefe would you estimate is taken up by the ulcers that you have identified?

MR. ALESSI: Just 10 and 15%. Thank you. Now, if we could look to the issue of — continuing with hypothermia, let's go to frostbite. Do you note any evidence of frostbite on the deceased, Mr. O'Keefe?

MR. ALESSI: Do you know what the weather conditions were in Canton, New York on the early morning? I'm sorry. I keep saying Canton, New York. My apologies. Do you know the weather conditions in Canton, Massachusetts, starting at midnight on January 29th, 2022, going through 6:00 a.m. on January 29th, 2022?

MR. ALESSI: Right. Correct. And when you say very cold, in addition to very cold, do you recall whether there were gusty winds?

MR. ALESSI: And do you understand that when there's a very cold temperature in Fahrenheit and you add gusty winds, that that is called — when you apply the two together — that's called windchill. Right?

MR. ALESSI: And with windchill, doesn't the phenomenon of windchill mean that the wind combined with a temperature brings the actual temperature down, and in addition to bringing it down, a windchill calculation also has a physical effect on the body. Correct?

MR. ALESSI: Doesn't windchill also cause greater effects than if there was no wind?

MR. ALESSI: So in medical terms, the wind synergizes with the temperature and exacerbates the effect on a human. Correct?

MR. ALESSI: And with windchill, wouldn't you — isn't it correct that you would have a greater chance of frostbite than if there was no windchill effect at all?

MR. ALESSI: So you saw no signs — no signs of frostbite on Mr. O'Keefe. Correct?

MR. ALESSI: Did you see frostbite at any other time with regard to Mr. O'Keefe?

MR. ALESSI: So at the only time you examined him, which is at the time of autopsy, you had zero signs of frostbite. Correct?

MR. ALESSI: Dr. Scordi-Bello, now that you have gone through this part of your examination here today, would you like to amend in any way your opinions as to whether hypothermia was any cause of the death of Mr. O'Keefe?

MR. ALESSI: Hypothermic signs.

MR. ALESSI: I'd like to move to another topic area, please. You did not include in your autopsy, in any fashion, any discussion of whether Mr. O'Keefe's injuries were consistent with a motor vehicle accident. Did you?

MR. ALESSI: In fact, there were no injuries consistent with a motor vehicle impact on Mr. O'Keefe. Correct?

MR. ALESSI: Did you evaluate at all in your autopsy whether Mr. O'Keefe had any injuries consistent with a motor vehicle accident?

MR. ALESSI: And could you elaborate to the jury what you mean by no evidence of an impact site?