February 15, 2018
from Spartanburg County J. Derham Cole, Circuit Court Judge
Rauch Wise, of Greenwood, for Appellant.
Attorney General Alan Wilson and Senior Assistant Attorney
General David Spencer, both of Columbia, and Seventh Judicial
Circuit Solicitor Barry J. Barnette, of Spartanburg, for
Stephanie Irene Greene appeals her convictions and sentences
for homicide by child abuse, involuntary manslaughter, and
unlawful conduct toward a child for the death of her infant
daughter, Alexis. Appellant was sentenced to prison for
twenty years for homicide by child abuse, five years
concurrent for involuntary manslaughter, and five years
concurrent for unlawful conduct toward a child. We affirm the
homicide by child abuse and unlawful conduct toward a child
convictions and sentences, but we vacate the involuntary
manslaughter conviction and sentence.
was Alexis's mother; she was Alexis's caretaker
during her brief life. Alexis died from morphine poisoning
when she was forty-six days old. Appellant, a former nurse,
was addicted to many drugs. The State contended that
Appellant's morphine addiction (as well as dependence on
other drugs) caused Alexis's drug poisoning through
breastfeeding. The jury convicted Appellant on all charges.
appeal followed. Appellant has raised four issues: (1)
whether the trial court erred in denying her motion for a
directed verdict on all charges due to the State's
failure to prove causation; (2) whether the trial court erred
in denying her motion for a directed verdict on the homicide
by child abuse charge due to the State's failure to prove
she acted with extreme indifference; (3) whether the trial
court erred in failing to instruct the jury that it could
only return a guilty verdict on one charge; and (4) whether
the trial court erred in failing to require the State to open
fully on the law and the facts of the case. We address each
of these issues in turn.
first assignment of error is the trial court's failure to
grant a directed verdict on all charges because the State
allegedly failed to produce any evidence that the morphine
found in Alexis came from Appellant's breast milk.
Appellant ignores the "synergistic effect" of the
morphine poisoning when considered along with Appellant's
abuse of other drugs. We have carefully reviewed the evidence
and, when viewed in a light most favorable to the State as
our standard of review mandates, we find sufficient evidence
to present all charges to the jury. State v.
Bennett, 415 S.C. 232, 235, 781 S.E.2d 352, 353 (2016)
(noting that when reviewing the denial of a directed verdict
the Court must not weigh the evidence but must view it in the
light most favorable to the State, for the Court is concerned
only with the existence or nonexistence of evidence)
State's causation theory was Appellant consumed excessive
amounts of central nervous system depressants, principally
morphine,  while breastfeeding Alexis and these drugs
passed through Appellant's breast milk, resulting in
evidence at trial revealed that Appellant continuously took
morphine-MS Contin-and other drugs while pregnant with Alexis
and while breastfeeding her. Moreover, the evidence showed
that Appellant took more morphine than her doctors
prescribed. In addition, Appellant exclusively breastfed
Alexis until approximately one week before her death.
Appellant told investigators that she began supplementing
with formula due to her new blood pressure medication;
however, Appellant also told investigators that she breastfed
Alexis extensively during the two nights immediately
preceding Alexis's death. Thus, sufficient evidence was
shown that Appellant took many drugs, including morphine, and
addition, the evidence presented at trial was sufficient to
show that the morphine and Clonazepam found in Alexis came
from Appellant's breast milk. Appellant contends there is
no evidence to support a finding that Alexis's drug
poisoning was the result of ingesting morphine through
Appellant's breast milk. We disagree, for we find the
evidence, when considered in its entirety, provides a
substantial basis from which a reasonable juror could
conclude Appellant's breast milk was the source of the
morphine that killed Alexis. The record includes extensive
scientific evidence on morphine and the synergistic effect
when combined with other central nervous system depressants.
This evidence included the varying rates of metabolism in
adults, the absence of metabolism in infants, the
transferability of morphine from a mother to her baby through
breast milk, and the risks of infants ingesting morphine (and
other drugs) from their mothers' breast milk.
David H. Eagerton, an assistant professor of pharmacology and
founding faculty member at the Presbyterian College School of
Pharmacy and the former chief toxicologist at the South
Carolina Law Enforcement Division, provided considerable
testimony. Part of that evidence included the warning
accompanying MS Contin, which provides that morphine
"passes into the breast milk":
Dr. Eagerton: "Before taking MS Contin
tell your healthcare provider if you have a history of
it." It gives several histories. And then in bold again
it says, "Tell your healthcare provider if you are
pregnant or planning to become pregnant. MS Contin may harm
your unborn baby. If you're breastfeeding MS Contin
passes into the breast milk and may harm your
of the scientific evidence addressed an infant's
inability to absorb and process a drug like morphine:
The State: And obviously the child died.
Obviously, it is consistent with that. Through the
breastfeeding and everything a child-can it metabolize drugs
like an adult does?
Dr. Eagerton: No, they don't.
The State: If you would, tell the jury about
that, especially a six-week-old.
Dr. Eagerton: Okay. Typically, whenever-just
to kind of back up a little bit how-you have to understand
what drugs do in your body.
Once-once you take them they don't stay there forever.
They go through a cycle. And in pharmacology we use the
acronym ADME absorption. You have to get the drug into your
system. So how do you get it in there?
There's-there's lots of different ways. You can-most
things we're talking about now is you think of it orally.
But you can give it, you know, as a shot either just under
your skin, in your muscle. You can give it [in an] IV
directly in your veins. You can absorb some drugs through the
skin, different things like that. So you have different
routes of administration depending on what you're trying
to do and what the drug is.
Once you absorb it it's going to distribute throughout
your body based on its chemical and physical properties, that
is whether it likes water or whether it likes fat, or it
distributes into one of those two areas in the body
Certain tissues may pick up drugs preferentially, things like
that. So it's going to distribute throughout your body.
Then the next step is metabolism, which is more correctly
termed biotransformation. Basically, your liver is
responsible for that, and it has enzymes that develop over
time that basically take these foreign compounds that
you're taking and make it usually more water [soluble],
and the idea is to make it either less toxic or more readily
excreted. But the idea i[s] to make it more readily-more
water [soluble] typically so that it could be more readily
excreted from your body. And that's the last stage of
elimination. And it's eliminated-it's eliminated-most
drugs are going to be once they're-especially once
they've been metabolized and made more water [soluble]
they're going to be eliminated throughout the water in
your body-urine, feces, sweat, saliva, tears, things like
that is how it's going to be eliminated primarily. There
are other ways too.
The State: Does a six-week-old child
metabolize at all?
Dr. Eagerton: No, not typically because it
take[s] time for your liver to develop. It takes time for
these-the genes that code for these enzymes to turn on and be
expressed. And you don't-even a child doesn't
metabolize things the same as an adult.
Usually you don't-whenever you go through puberty is
whenever most of the things that are going to turn on for an
adult is going to turn on.
And, in fact, it even goes the other way. As you get old,
become aged, some of these genes can become nonfunctional.
Some-you may not have the same metabolic capacity.
Your kidneys may not work as well, things like that. So you
have to take into consideration age certainly whenever
you're looking at the effects of drugs and how long
they're going to stay in your body.
The State: Obviously, the baby Alexis showed
signs of this before the death.
Dr. Eagerton: Right. The-the lethargy, maybe
trouble breathing. I-I don't know how to interpret that
exactly, but there [were] some-there were some symptoms that
were conveyed that were consistent with morphine toxicity.
The State: And basically if she was
continuously breastfeeding and things like that could she
reach a level, especially if she didn't metabolize it
nearly as fast as the mother, for example, could it reach the
levels of toxicology-toxicity of the level [sic]?
Dr. Eagerton: Yes. And that's one of the
things that if you can't metabolize it, then the drug may
build up in your body and you become-you have a toxic dose
whenever you wouldn't normally have a tox[ic] dose.
Eagerton's testimony further included the warning on
morphine from LactMed:
Dr. Eagerton: "Epidural morphine given
to mothers for post[-] cesarean section analgesia results in
trivial amounts of morphine in their colostrum and milk.
Intravenous or oral doses of maternal morphine in the
immediate postpartum period result in higher milk levels than
with epidural morphine. Labor pain medication may delay the
onset of lactation. Maternal use of oral narcotics during
breastfeeding can cause infant drowsiness, central nervous
system depression and even death."
Dr. Eagerton: "[A]t least some of
[the morphine] I believe within a reasonable degree of
scientific and medical certainty had to come through the
this evidence as true-as we must under the standard of
review-one may reasonably deduce that morphine ingested
through breastfeeding "can cause . . . death." The
evidence, scientific and otherwise, further allows a
reasonable juror to conclude that Appellant's breast milk
was the source of the morphine found in Alexis's body.
Thus, the testimony of Dr. Eagerton provides evidence that,
if believed, is sufficient to survive Appellant's
directed verdict motion. The State presented additional
John D. Wren, a pathologist, performed the autopsy on Alexis.
Dr. Wren is an experienced pathologist, having performed more
than four thousand autopsies. Early in Dr. Wren's
testimony, the State established that Alexis's body had
no needle marks. Dr. Wren stated that "the only way this
child could have gotten that much [morphine] would be orally,
because I saw no injection sites. . . . The route of
administration had to have been orally." And as Dr. Wren
explained, the level of morphine in Alexis was lethal:
Dr. Wren: Then you come to morphine. The
level was .52 mg per liter, therapeutic level was .10 to .30
mg per liter. And from my references therapeutics [sic] .001
to .200. Toxic is .3 to 2.5. And lethal is .2 to 7.2.
Now, you'll notice that some of these overlap. It really
depends on how the-how accustomed the body is to that
And then in pieds [sic]-I put this in because I had found
this later-that the levels that produce surgical analgesia in
pediatrics is .046 to .083, which is 46 to 83. Once again,
the level reported [in Alexis] is 520. And then of course
there's a caveat there. Lethal levels may be higher in
individuals under chronic opioid treatment.
If you have a person that's under chronic opioid
treatment they're taking in a lot-a lot often and
they're-over a long period of time they adjust to
the-their body physiology adjusts to that, and they can
sustain higher levels without it having an effect on them.
So you have to take into account where the person has a
history of that-and of course nobody that comes to the morgue
is going to tell you they're taking morphine, and
sometimes the family don't tell you either. So we have to
take it if they don't have a prescription that
they're getting it illegal[ly] or they're taking
So based on all of that all of these drugs essentially
lead to respiratory depression. And so I said based on
the history and autopsy findings-and I should have put in
including toxicology results-it was my opinion that this
child died as a result of respiratory insufficiency secondary
to synergistic drug intoxication. I could just as easily have
said morphine intoxication, but lawyers like to split hairs,
and so I included them all.
(emphasis added). Dr. Wren's testimony continued:
The State: And, Doctor, let me ask you this.
Obviously, being a young child, six-and-a-half weeks, her
metab-the ability to metabolize drugs, is it much less than
Dr. Wren: That's-that's correct. It
The State: So it will build up over a period
of time if it-if it keeps getting the drugs.
Dr. Wren: Yeah. If they can't metabolize
it'd have to go somewhere. And there's something
called intrahepatic circulation. If it's excreted into
the bile or whatever, it gets into the GI tract, and it's
reabsorbed and goes back in[, ] it just recirculates.
It's just not eliminated unless she's-has affluent
diarrhea or-or urinating all of the time.
The State: So, and the-the mother was taking
morphine in this situation and breastfeeding. Obviously, the
baby was getting morphine though ...