THEORIES

Theory One: Fatal beating based on internal bleeding (Nov. 2006)

Fact: Physiologically impossible to have internal bleeding w/o external bruising while on warfarin
(Coumadin). Internal bleeding caused by warfarin overdose (discovered by parents; documentation
provided to State on Dec. 18, 2006).

Theory Two: Blow to head caused skull fracture 24-hrs/before death. May be intentional or accidental.
Severe headache. No treatment. Neglect. (April-May 2007)

Fact: Post-mortem fracture, created at autopsy. Symptoms consistent with flu & menstrual period, not
skull fracture.

Theory Three: Didn’t take monthly blood tests (INRs) as instructed by doctors; didn’t take to doctors
regularly. Neglect. (April 2007)

Fact: Over 1,000 pages of medical records showed consistent care, no doctor orders for INRs.

Theory Four: Observed bleeding + decline in health (week before death) + pre-existing conditions (heart,
seizure) = neglect (Sept. 2007)

Fact: Observed bleeding = first menstrual period, minimal bleeding from sore on lip/tongue
All other bleeding internal or occurred at/after death (consistent with coumadin)
Decline in health = flu-like symptoms (diagnosed by dr.) + menstrual period
No observed symptoms of pre-existing conditions (cyanosis, respiratory problems, seizure)

Presupposition: Lynnette and Roman had sophisticated knowledge of warfarin and should have been
able to detect warfarin overdose.

Fact: Medical records show no instructions, education, no orders for monthly INRs
FDA black box warning did not come out until October 2006.
Doctor’s responsibility to prescribe blood tests, educate and re-educate patient and parents.
Jessica presented to doctor one week before death w/symptoms consistent with Coumadin
overdose. Doctor sends home with no blood work. Orders clear liquid diet and to come back in a
week if not better.
Very difficult for doctors (let alone patients/parents) to detect over-anticoagulation.

MISTAKES

1. Cardiologist does not order monthly blood test (INRs); no parent/patient education on warfarin, as
required by national standards (1996-2005).

2. Family physician writes prescription that increased Coumadin by 133%. Does not order INRs.
National standards allow maximum 20% increase & require INRs (daily/weekly with increased dose,
then monthly). Error increased risk of fatal bleeding. Additional prescription error eliminated
Phenytoin (Dilantin) (to control seizures).

3. Pharmacist does not catch prescription error. (New customer. Pharmacist not familiar with patient.)

4. School officials mandate vaccination, under penalty of expulsion, that contraindicates medication and
is contrary to their own immunization policy. Family physician okays.
5. When brought to family physician, no blood work is done. Prescriptions & instructions increase effect
of Coumadin overdose.

6. Forensic pathologist creates skull fracture, does not recognize internal bleeding (particularly brain
bleeding) as artifacts of Coumadin overdose and takes 19 months to file official report. No external
trauma other than bruise on knee, possible slight bruise on forehead where fell; attributes death to
subdural hemorrhage caused by blunt force trauma to head consistent with fall (typical description of
coumadin death); manner of death undetermined. Also records that Jessica’s prostate is “firm with no
evidence of enlargement.” (Women do not have prostates).

7. Forensic pediatrician theorizes a fatal beating based on limited facts provided by DCS. Does not get
pharmacy records; does not understand that lack of bruising precludes fatal beating for warfarin
patient. Later admits she is not qualified to rule on cause or manner of death and has no expertise in
Coumadin or Fontan procedure.

8. State consistently refuses to talk to parents or discuss medical evidence. Children taken & charges
filed based on mistaken theories (later dropped).

9. Prosecutor given permission to talk to all experts (below); indicates she will call Pless, Leestma,
Lambert, Nutescu; special arrangements made to talk to Leestma, who is on vacation. Talks to
Pless, who explains post-mortem fracture. Drops previous charges but does not follow up with other
experts, refuses to discuss symptoms, resulting in new charges (theory 4), also incorrect.

State’s Position:
• Doctors not held accountable for mistakes (would be malpractice for most)
• Parents should be held criminally responsible for prescription error that was not detected by
doctors or pharmacist.

CONSEQUENCES FOR FAMILY

1. Lost daughter/sister due to prescription error.

2. Surviving children taken to undisclosed location in a different county with limited supervised visitation
for nine months to allow State to investigate cause of death. Given false information regarding what
happened to sister while subject to improper investigative therapy, police interrogation, etc.

3. Relationship with son destroyed due to false information provided by State.

4. Jessica dug up and dissected, adding to grief of family.

5. All major holidays, birthdays, school year and entire summer lost to family.

6. Roman and Lynnette arrested while preparing to meet with prosecutor to discuss medical records,
medical evidence and symptoms.

7. Media reports Francesville couple arrested for the death of fourteen-year-old daughter.

8. Roman and Lynnette not allowed to attend Johnathon’s graduation party; family prevented from
sitting together at graduation.

9. Roman missed interview with gaming commission that could have resulted in a $10,000 a year pay
increase.

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10. Roman suspended from job without pay (trainer with DOC, 17 years). Family lost all income,
insurance, possibly house. Rejected from collecting unemployment because it was reported that he
was suspended for misconduct leading to his arrest.

SUMMARY OF MEDICAL CONCLUSIONS

Dr. Kenneth Ahler MD, Jasper County Hospital ER and former Jasper County Coroner. Did a thorough
inspection because of concerns about blood at the scene.

Conclusion: “Sudden death syndrome. Congenital Heart Disease. There was no obvious
history of trauma and none could be witnessed except for bruising on the right knee. .
“According to Dr. Hurwitz (sic) there are only 200 of these cases in the country that have
survived the surgery and the ones that have died 2/3 of them have been sudden death as
was the case [here].”

These conclusions were available to all parties on day of death.

Dr. Harold Buttram MD, family practice.

Conclusion 1: “It is my opinion within a reasonable degree of medical certainty that Jessica
died from a fulminating hemorrhagic disorder, most likely in the form of
thrombocytopenia, which was triggered by an anamnestic response to vaccines
administered on 12-5-05. I do not believe that the clinical evidence supports charges of
parental blunt trauma for any of the autopsy findings.”

Conclusion 2: “As set forth in my preliminary e-mail, it is apparent that Jessica’s death was
caused by her underlying medical conditions (congenital heart disease and seizure
disorder) and a prescription error that more than doubled her warfarin and eliminated
dilantin, compounded by unmonitored vaccinations and the failure of her doctors to take
regular INRs, particularly when she presented with flu-like symptoms. It now appears that
the skull fracture was also medically-induced, i.e., caused by autopsy.

It would indeed be a sad commentary on our times if the medical errors which contributed
to Jessica’s death were compounded by continued, misguided prosecution of Jessica’s
parents with the devastating effects that would ensue for the entire family. Let us hope
this does not happen.

Having reviewed over 90 cases of child death or abuse since 1999, the prosecution in the
present case has been among the most misguided and egregious that I have seen. For this
reason I predict that, unless the prosecution is stopped from further harassing this
unfortunate family, the case will in time reflect badly on the medical and legal systems
which allowed it to happen and be a cause of regret for all concerned.”

Dr. Buttram’s initial conclusion was shared with all parties on December 18, 2006.

Bruce Lambert, Professor, University of Illinois School of Pharmacy, national expert on prescription
error.

Conclusion: “Given the unexplained increase in Jessica’s Warfarin dose and the
discontinuation of Phenytoin (Dilantin), serious consideration should be given to the
possibility that Jessica’s death was caused by one or more prescribing errors, combined
with her underlying heart condition and reported illness in the days before her death.”

This was signed on January 4, 2007 and shared with all parties.

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Dr. Michael Innis, MBBS; DTM&H; FRCPA; FRCPath Emeritus Consultant Haematologist:

Conclusion: “I conclude that, to a reasonable degree of medical certainty, Jessica’s death

was the result of an undetected complication of Coumadin therapy, possibly triggered by a
prescription error. The mandated DPT vaccinations, ill health and the removal of Dilantin
from her medication regimen may have aggravated the situation.” He also explained that
Coumadin causes a decrease in bone density, which would have made her susceptible to
fractures.

This was signed in January 2007 and shared with all parties.

Edith Nutescu, University of Illinois School of Pharmacy and leading expert on Coumadin/warfarin.

Conclusion: “Even if a warfarin patient has been stable for an extended period, it is also
critical to have a very clear follow-up plan, with clear directions to the patient or the
patient’s parents. Jessica’s medical records suggest a lack of coordination between her
physicians, resulting in an almost complete system failure. Several failures are obvious.
First, the prescribing physicians are responsible for ordering monthly INRs and ensuring
that they are taken. Such orders should be written in prescription form and recorded in
the patient’s chart. If the patient or the patient’s parents do not comply with these orders,
the physician should not refill the prescription as the risk of therapy may outweigh the
benefit. Second, the treating physicians are responsible for taking INRs when the patient
presents with illness or other conditions that might increase the effect of warfarin. Third,
it is the physician’s responsibility to educate and re-educate patients or the patient’s
parents on the dangers of warfarin. Fourth, when care is shared between physicians, the
physicians are responsible for coordinating the patient’s care, including the scheduling of
INRs. In this case, it appears that none of these steps were taken.”

“Because it is not possible to detect internal bleeding, warfarin deaths are often
characterized by sudden collapse following an illness. Patients who are over-
anticoagulated may be asymptomatic or have flu-like symptoms, i.e., they may feel sick,
dizzy or tired and may have a headache or stomachache. These symptoms may be
followed by death or cardiac arrest without further warning.

As this suggests, it is extremely difficult to detect the signs of over-anticoagulation or

internal bleeding. When Jessica’s prescription increased from 3 to 5 or 7 mg, one would
not necessarily see any symptoms even though she would be at increased risk of internal
bleeding. Triggering factors such as illness, other medications and dietary changes would
then push the INR higher, causing noticeable illness. Since internal bleeding is not
apparent, such illness may be attributed to the flu or, in Jessica’s case, a first menstrual
period. This is very characteristic of warfarin and is the primary reason that warfarin is
such a dangerous drug.”

This was signed in May 2007 and shared with all parties. Dr. Nutescu explained impact of
warfarin in greater detail in a July 2007 deposition, shared with all parties.

Dr. John Pless MD, Forensic Pathologist, Clyde G Culbertson Professor Emeritus, Indiana University
School of Medicine. (Reviewed autopsy report, slides and photographs of fracture and subdural
nd
hemorrhage taken at 2 autopsy.)

Conclusion: Dr. Pless wrote that the pathologist who conducted the autopsy made several
mistakes. The first was “ when he created a skull fracture opening the cranium initially.” His
second mistake was that “he did not sufficiently account for the hemorrhage seen in
multiple areas of the body as artifacts of Coumadin (blood thinner) therapy.” The third
mistake was “taking so long to assemble his final report.”
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 He further concluded, “Clearly, this death is the result of natural disease” and that “It is a
credit to the parents of this child that she was able to survive as long as she did.

This letter was written July 10, 2007 and shared with all parties.

Dr. Jan Leestma, Forensic Neuropathologist, author of leading neuropathology text.

Conclusion: Slides showed that small subdural hemorrhage was old, consistent with the
overdose and thus could not be immediate cause of death (as suggested by original
forensic pathologist). Referring to the fracture he stated, “In this case, the skull fracture does
not seem to be associated with a significant impact in the days prior to death since, given
the increase in Warfarin, an impact sufficient to cause this fracture would also cause
extensive subgaleal and subdural hemorrhages, which do not appear to be
present…possibility is that the skull fracture was created at autopsy. There are several
ways to remove the skull cap, each of which creates different risks of creating post-
mortem fracture…the site of the fracture, which appears below but not above the saw line,
suggests that the fracture may have been caused at autopsy. It would be quite
coincidental for the saw line to pass through the precise beginning of a fracture…[t] he
absence of apparent blood in the fracture line also suggests that the fracture occurred at
autopsy. Since vessels in the bone marrow bleed when a bone is fractured, the absence
of blood in a fracture suggests that the fracture occurred after death. While one
photograph suggests that there may have been some blood in the fracture, others indicate
that there was no blood in the fracture, suggesting that the fracture occurred after death.”

After review of additional material, Dr. Leestma noted that the fracture was definitely postmortem; that the
State had confused the impact of hemorrhages due to warfarin with a beating; and that the death was
natural/accidental due to some combination of warfarin and her underlying heart condition and seizure
disorder. Dr. Leestma’s conclusions were shared with all parties.

Dr. R. Gordon Klockow, Jasper County Coroner. The death was ruled accidental due to long term
Coumadin overdose.

Conclusion: “I find that Jessica … died an accidental death from sudden cardiac arrest due
to seizure due to cerebral anoxia due to long term Coumadin overdose and a loss and lack
of Dilantin as a result of medication errors.”

“A vaccination of Tetanus and Polio (killed virus) was given two weeks prior to her death
without consultation by her cardiologist. This vaccination would have altered her immune
system in an unknown and unpredictable way.”

“All skull fractures were artifacts of the autopsy. The evidence in person and
photographically indicates Green stick fractures postmortem.”

The Coroner’s verdict was filed on July 17, 2007 and provided to all parties. It is our understanding that
the Coroner personally reviewed the information with the prosecutor on the day of the verdict.

SUMMARY OF CONCLUSIONS
ON TREATMENT OF CHILDREN DURING FOSTER CARE

Dr. Randall Krupsaw, a psychologist specializing in child development and evaluation.

Conclusion: “I am concerned with the evidence in the progress reports suggesting that the
children’s therapists have felt duty bound to investigate Jessica’s death, to supply

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 information to the children about what might have happened, and to report their findings
to DCS…
This is improper and can have adverse effects, some of which may have already
occurred…
The information obtained may be inaccurate and may influence subsequent interviews or
interrogations….
Using therapists to obtain information for a legal case is contrary to the purpose of
therapy and may shut down the willingness of the children to talk…
the children have been caught between their parents, to whom they wish to return, and
DCS, which apparently wishes to obtain information from them to use against their
parents…
Although the failure to disclose abuse or neglect over eight months strongly suggests that
no abuse or neglect occurred, it may be difficult to disabuse the children of any
misconceptions that they may have acquired during this period of restricted contact.”

Dr. James Kenny, Clinical Psychologist.

Conclusion: “After reviewing documents, interviewing the parents and conducting

standardized psychological testing, I concluded that Lynnette and Roman are
psychologically healthy and have adequate parenting skills. I understand that my reports
have been previously provided to DCS and the courts. As set forth in my reports,
Lynnette’s knowledge and understanding of her children and their needs was impressive
and consistent with teacher affidavits. As noted in many letters of recommendation and
commendation, Roman’s attributes included honesty, compassion, patience and good
communication skills … the same skills found in effective parents. The parents’
cooperation and commitment to their children’s well-being and the efforts they had made
to ensure their children’s return were also impressive.”

“In reviewing the file, I concurred with the conclusions of Dr. Randall Krupsaw, whose
affidavit was previously provided to DCS and the courts. As Dr. Krupsaw notes, the
progress reports from the children’s therapists during the separation indicate that the
therapists, including ****** ******, were using therapy to investigate Jessica’s death, supply
information to the children on what may have happened, and report their findings to DCS.
This is contrary to the ethical standards for psychologists and is known to produce false
disclosures of neglect or abuse.”

“I concur with Dr. Krupsaw’s conclusion that the girls’ failure to disclose abuse or neglect
over nine months of investigative therapy indicates that they were not subjected to abuse
or neglect and that they did not see abuse or neglect in their household.”

“There is an urgent need for the Court to simplify this unwieldy and destructive situation.
At present, the children are caught in the middle between their parents and competing
providers and are understandably confused by multiple pressures, causing added stress.
The children’s need for “one voice” must be paramount. If the girls are to live with the
Finnegans, as agreed by all parties, the parents need to be in charge of parenting and the
family needs to be active participants in determining which, if any, of the competing
services and personnel are helpful. Otherwise, all of the service providers will cancel each
other out, with continued power battles and competing advice.”