Anna Nicole Smith accidentally overdosed on at least nine prescription drugs - including a powerful sleep syrup she was known to drink right out of the bottle - after a miserable last few days in which she endured stomach flu, a high fever, pungent sweating and an infection on her buttocks from repeated injections.
In a detailed autopsy report released Monday, a medical examiner noted the former Playboy playmate refused to go to a hospital three days before her Feb. 8 death. She chose to endure her illness in a hotel suite littered with pill bottles, soda cans, SlimFast, nicotine gum and an open box of Tamiflu tablets.
Broward County Medical Examiner Dr. Joshua Perper found that in the days before her death, the 39-year-old Smith had been taking large amounts of the seldom-prescribed sedative chloral hydrate, which also contributed to the 1962 overdose death of Smith's idol, Marilyn Monroe.
Police found no apparent sign of foul play, and the medical examiner ruled Smith's death probably was not a suicide because people who take their own lives typically use much more lethal drugs than chloral hydrate.
Rather, he said, Smith might have been simply unaware that the sedative could be fatal in combination with the multiple other prescriptions she was taking in normal doses for anxiety, depression and insomnia.
Contributing factors included her weakened condition from a stomach flu and a 105-degree (40-degree Celsius) fever brought on by a pus-filled infection on her buttocks from repeated injection of other drugs.
"She may have taken the dosages she was accustomed to but succumbed because she was already weakened," Perper said in his report. "Miss Smith has a long history of prescription drug abuse and self-medicated in the past."
The recommended dose of chloral hydrate is one to two teaspoons before bed. Smith often took two tablespoons, and she sometimes drank directly from the bottle, the report said.
A statement issued by lawyers for Howard K. Stern, Smith's companion who was with her before her death, said that Stern and Smith's physician urged her to get emergency treatment but she refused because "she did not want the media frenzy that follows her."
"She refused to go to the hospital because she wanted to avoid media," attorney Lilly Ann Sanchez said in a news release. "Anna called the shots in Anna's life and everyone close to her knows that."
The autopsy report left some unanswered questions such as why it took so long for emergency personnel to be summoned when Smith was discovered unresponsive Feb. 8 in her room at the Seminole Hard Rock Hotel and Casino.
The report found that a private nurse had asked a bodyguard to call 911 around 1 p.m. and had started CPR. The Seminole EMS was called about 1:40 p.m. by a bodyguard and arrived six minutes later. The ambulance reached the hospital at 2:43 p.m., and Smith was pronounced dead shortly thereafter.
Perper said Smith could have been saved had she been hospitalized earlier in the week simply because her drug intake could have been controlled.
"If she would have gone to the hospital she wouldn't have died because she wouldn't have had the opportunity to take the excessive amount of chloral hydrate," he told The Associated Press.
But Perper said the lag in calling 911 on the day of Smith's death probably did not matter.
"The earlier you come to a hospital the more you have a chance, but there's not a guarantee," he said. "Those are not things with a mathematic precision, but within a reasonable degree of medical certainty, I don't think she had really a realistic chance."
Perper said he believed at least three doctors had prescribed Smith drugs using a number of aliases, but all the medication was meant for her.
Stern lawyer Sanchez said the chloral hydrate was prescribed for Smith by her friend and psychiatrist, Dr. Khristine Eroshevich, who also traveled with her to Florida. Sanchez said the drug was prescribed last year after Smith's 20-year-old son, Daniel, died in the Bahamas of apparent drug-related causes.
"She was having nightmares. She was having hallucinations. She was unable to sleep," Sanchez said, adding that Eroshevich turned to "an older, tried and true drug" because it was more effective for Smith than newer sleeping medicines.
Perper said Smith also had been on several antidepressant and anti-anxiety drugs and had recently been injecting herself with purported longevity medications, vitamin B-12 and growth hormone.
She felt ill shortly after arriving in Fort Lauderdale from the Bahamas on Feb. 5 on a trip with Stern to buy a new yacht. But that illness was brought under control by antibiotics and an ice bath. She also suffered intense, pungent sweating that soaked the sheets. An assistant medical examiner's report described seeing a table in Smith's hotel room containing cold medicine, sodas cans, SlimFast, nicotine gum and an open box of Tamiflu tablets.
Seminole Tribal Police Chief Charlie Tiger said investigators found nothing unusual on laptop computers belonging to Smith and Stern. Tiger also said nothing came up during an exhaustive review of tapes from hotel security cameras and from interviews with numerous witnesses.
The public airing of the details of Smith's death reflected the way she lived her life.
A high school dropout in Texas, she gained fame as Playboy Playmate of the Year, a model for Guess jeans and later a star in her own reality show. She married 89-year-old oilman J. Howard Marshall II, and after his death took her fight for Marshall's estimated $500 million fortune as far as the Supreme Court. That ongoing battle could make her infant daughter, Dannielynn, very wealthy. Stern and two other men have claimed to be the baby's father, reports AP.
The medical examiner's report was accompanied by a press release and even a PowerPoint presentation. Among the details were descriptions of Smith's breast-enhancement scars, her pink hair extensions and numerous tattoos, including one of a Playboy bunny, a Bible intertwined with a heart and shooting flames, and the smiling face of Marilyn Monroe.