Insights from coronial recommendations for preventing natural deaths in sport and recreation in Québec, Canada.

Introduction: This descriptive retrospective study analyzed coronial recommendations for natural deaths in sport and recreation from January 2006 to December 2019 using data from the Bureau du coroner du Québec. Methods: Reports with recommendations were analyzed by sex, age group, cause of death, context, and activity. The nature of recommendations was assessed using a public health-based model. Thematic analysis was conducted following a four-phase approach in which themes developed were emphasized and further connected with existing literature. Results: Reports involving individuals aged 18-24 and reports related to ice hockey were significantly more likely to contain recommendations. Reports related to individuals ≥45 years old, or related to cycling or hunting had higher death frequencies, but relatively low recommendation rates. Most recommendations aligned with the public health-based model but specifying implementation time frames was rare (11.7%). Nearly 60% of coroner's recommendations focused on automated external defibrillator implementation, delivery and training. Discussion: Mitigation of sudden cardiac arrest risk for individuals ≥45 years old, timely treatment of life-threatening arrhythmias especially for activity practiced in remote regions and specifying implementation time frames were identified as improvement areas. The multi-faceted approach to enhancing public access defibrillation developed by the International Liaison Committee on Resuscitation in 2022 addresses recurrent themes covered by coroners and holds the potential to inform evidence-based decision making.

Improving state medicolegal death investigation: Does system level reform improve public health data concerning drug-related mortality?

In the United States, the governance of unnatural death certification varies greatly by state. Although cross-sectional research has linked mortality data quality with variation in medicolegal death investigation systems across states-especially with regards to drug-related deaths-this relationship has not be sufficiently tested using longitudinal data. This research assesses the impact of system governance reform on the quality of drug mortality data by assessing the impact of transitioning from a coroner system to a medical examiner system on data quality. The research finds no evidence that system-level reform is associated with improved drug-related mortality data quality. These findings suggest that alternative methods should be examined for improving public health data concerning drug-related mortality. These likely include focusing on individual-level characteristics and practices of officials and offices, rather than system-level variables.

Evaluation of in-house drug evidence testing by King County Medical Examiner's Office in "real-time" fatal overdose surveillance.

With the escalating overdose epidemic, many surveillance efforts have appeared. In 2018, King County Medical Examiner's Office (KCMEO) initiated a fatal overdose surveillance project aimed at expediting death certification and disseminating timely information. In this project, KCMEO investigators collected items of evidence of drug use from overdose death scenes, which were tested by five in-house methods, four using handheld devices: TruNarc Raman spectrometer, with and without the manufacture's H-Kit, Rigaku ResQ Raman spectrometer, and MX908 mass spectrometer. The fifth in-house method used fentanyl-specific urine test strips. Results from in-house testing were compared with results from Washington State Patrol (WSP) Materials Analysis Laboratory. From 2019 to 2022, there were 4244 evidence items of drugs and paraphernalia collected from 1777 deaths scenes. A total of 7526 in-house tests were performed on collected specimens, and 2153 tests were performed by the WSP laboratory using standard analytical methods. The WSP results served as reference standards to calculate performance metrics of the in-house methods. Sensitivities, specificities, and predictive values ranged from good to poor depending on the method, drug, and evidence type. Certain drugs were often associated with specific evidence types. Acetaminophen was frequently found in combination with fentanyl. Fentanyl test strips gave good scores for detecting fentanyl; otherwise, in-house methods using handheld devices had poor performance scores with novel drugs and drugs diluted in mixtures. The results showed that in-house testing of drug evidence has value for medical examiner overdose surveillance, but it is resource intensive, and success depends on collaboration with forensic laboratories.

Causes of Death in the Presence of Law Enforcement in Johnson County, Iowa, 2011-2020.

Objectives. To examine sudden and unexpected or trauma-related deaths that occurred in the presence of law enforcement in Johnson County, Iowa, between 2011 and 2020. Methods. We identified deaths in the presence of law enforcement using definitions from the National Association of Medical Examiners. We obtained data, including demographics, cause and manner of death, toxicology results, and circumstances and location of event leading to death, from comprehensive medical examiner investigative reports. Results. There were 165 deaths that occurred in the presence of law enforcement: 114 were from a known disease, and 51 were either trauma related or the sudden, unexpected initial presentation of a previously unrecognized disease. Three deaths occurred in the context of physical restraint by law enforcement. Suicide was the leading manner of death among trauma-related deaths; the means of suicide was predictable based on in-custody (hanging) or precustody (firearm) circumstances. Conclusions. Our findings highlight the potential role of medical examiners and coroners in improving completeness of data on reporting death in the presence of law enforcement to public health agencies. (Am J Public Health. 2024;114(6):642-650. https://doi.org/10.2105/AJPH.2024.307616).

Thematic analysis of Prevention of Future Death reports for suicide: January 2021 to October 2022.

BACKGROUND: Suicide prevention remains a high priority topic across government and the National Health Service (NHS). Prevention of Future Death (PFD) reports are produced by coroners to highlight concerns that should be addressed by organisations to prevent future deaths in similar circumstances. OBJECTIVE: This research aimed to understand themes from concerns raised in PFD reports for deaths from suicide to inform future policies and strategies for preventing suicide. METHODS: We employed a retrospective case series design to analyse PFD reports categorised as suicide using qualitative inductive thematic analysis. Primary themes and subthemes were extracted from coroners' concerns. Following theme extraction, the number of concerns coded to these themes across reports and the frequency of recipient organisation being named as addressee on these reports were assessed as primary outcomes. FINDINGS: 12 primary themes and 83 subthemes were identified from 164 reports (4% of all available reports). The NHS was the most frequent recipient of these reports, followed by government departments. Coroners raised issues around processes within or between organisations and difficulties accessing services. The most common concerns fell under the primary theme 'processes' (142 mentions), followed by 'access to services' (84 mentions). The most frequent subthemes were 'current training not adequate' (38 mentions) and 'inadequate communication between services' (35 mentions). CONCLUSIONS: Our results specify areas where review, improvement and policy development are required to prevent future suicide deaths occurring in similar circumstances. CLINICAL IMPLICATIONS: These themes highlight concerns across current care and service provision where reform is required for suicide prevention.

What Are the Experiences of Mental Health Practitioners Involved in a Coroner's Inquest and Other Inquiry Processes after an Unexpected Death of a Patient? A Systematic Review and Thematic Synthesis of the Literature.

Grief after suicide or patient-perpetrated homicide can be complex for those involved in the patient's care. Mental health practitioners with patients who die unexpectedly may be called to assist in the formal investigation processes that follow. The aim of this study was to examine the experience of mental health practitioners called to attend a coroner's inquest or other forms of formal inquiry. A protocol for a systematic review was prospectively registered on PROSPERO (CRD42023400310). A thematic synthesis of existing literature was conducted. We identified six articles for inclusion and constructed three themes from our analysis: Blame and enduring hostility, In the dark, and Limited learning. We found mental health practitioners may construct narratives of self-blame. These can be reinforced by the investigatory processes that follow. Feedback from inquiries is often delivered haphazardly and may not reflect the realities of clinical work. The support given to assist practitioners through inquiry processes varied-both in amount and how helpful it was. The research conducted on this topic is limited. More qualitative research should be conducted to understand the factors that make this experience more or less difficult as well as well as what support is needed for whom.

Using death investigation data to better understand the overdose crisis. / Utiliser les données d'enquête sur les décès pour mieux comprendre la crise des surdoses.

INTRODUCTION: The collection of articles in this theme series of the journal presents results from a national chart review study of the death investigation files of people who died of acute toxicity in Canada between 2016 and 2017. This study endeavoured to better understand the characteristics of the people who died, the circumstances of their deaths and the substances involved. While information about the study and some of its findings have previously been published, we would like to share more about how the study came to be, the people involved and the value of collaborative efforts between coroners, medical examiners and public health practitioners.

Timely and comparable data are essential to the development of a robust evidence base that public health professionals can use to address the evolving national overdose crisis and its drivers. Key to developing this evidence base is fostering collaborative relationships between multidisciplinary teams, including the public health sector and the coroner and medical examiner community.

Il est essentiel de disposer de données comparables et à jour pour constituer une base de données probantes solide dont les professionnels de la santé publique pourront se servir pour lutter contre la crise nationale des surdoses à mesure qu'elle évolue et contre les facteurs qui en sont à l'origine. Le développement de cette base de données probantes repose sur la collaboration d'équipes multidisciplinaires, composées notamment de membres du secteur de la santé publique et des coroners et des médecins légistes.

Rapid Identification of Suspected Drug Overdose Deaths by Death Investigators, New Jersey, 2020.

OBJECTIVE: While the number of overdoses in the United States continues to increase, lags in data availability have undermined efforts to monitor, respond to, and prevent drug overdose deaths. We examined the performance of a single-item mandatory radio button implemented into a statewide medical examiner database to identify suspected drug overdose deaths in near-real time. MATERIALS AND METHODS: The New Jersey Office of the Chief State Medical Examiner operates a statewide mandated case management data system to document deaths that fall under the jurisdiction of a medical examiner office. In 2018, the New Jersey Office of the Chief State Medical Examiner implemented a radio button into the case management data system that requires investigators to report whether a death is a suspected drug overdose death. We examined the performance of this tool by comparing confirmed drug overdose deaths in New Jersey during 2020 with suspected drug overdose deaths identified by investigators using the radio button. To measure performance, we calculated sensitivity, specificity, positive predictive value, negative predictive value, and false-positive and false-negative error rates. RESULTS: During 2020, New Jersey medical examiners investigated 26 527 deaths: 2952 were confirmed by the state medical examiner as a drug overdose death and 3050 were identified by investigators using the radio button as a suspected drug overdose death. Sensitivity was calculated as 96.1% (2837/2952), specificity as 99.1% (23 362/23 575), positive predictive value as 93.0% (2837/3050), negative predictive value as 99.5% (23 362/23 477), false-positive error rate as 7.0% (213/3050), and false-negative error rate as 3.9% (115/2952). PRACTICE IMPLICATIONS: Implementation of a radio button into death investigation databases provides a simple and accurate method for identifying and tracking drug overdose deaths in near-real time.

Accidental substance-related acute toxicity deaths among youth in Canada: a descriptive analysis of a national chart review study of coroner and medical examiner data. / Décès accidentels attribuables à une intoxication aiguë due à une substance chez les jeunes au Canada : analyse descriptive d'une étude nationale portant sur l'examen des dossiers des données de coroners et de médecins légistes.

INTRODUCTION: Substance-related acute toxicity deaths (ATDs) are a public health crisis in Canada. Youth are often at higher risk for substance use due to social, environmental and structural factors. The objectives of this study were to understand the characteristics of youth (aged 12-24 years) dying of accidental acute toxicity in Canada and examine the substances contributing to and circumstances surrounding youth ATDs. METHODS: Data from a national chart review study of coroner and medical examiner data on ATDs that occurred in Canada between 2016 and 2017 were used to conduct descriptive analyses with proportions, mortality rates and proportionate mortality rates. Where possible, youth in the chart review study were compared with youth in the general population and youth who died of all causes, using census data. RESULTS: Of the 732 youth who died of accidental acute toxicity in 2016-2017, most (94%) were aged 18 to 24 years. Youth aged 20 to 24 who were unemployed, unhoused or living in collective housing were overrepresented among accidental ATDs. Many of the youth aged 12 to 24 who died of accidental acute toxicity had a documented history of substance use. Fentanyl, cocaine and methamphetamine were the most common substances contributing to death, and 38% of the deaths were witnessed or potentially witnessed. CONCLUSION: The findings of this study point to the need for early prevention and harm reduction strategies and programs that address mental health, exposure to trauma, unemployment and housing instability to reduce the harms of substance use on Canadian youth.

Homicide Manner-of-Death Classification in Arrest-Related Death.

ABSTRACT: Multiple studies have documented various factors that influence or determine forensic pathologist classification of manner of death. There do not appear to be any published studies on manner of death classification specifically regarding arrest-related deaths (ARDs). The goal of this study was to consider a large body of cases of nonfirearm ARDs to analyze the homicide classification with regards to numerous decedent and practitioner (medical examiner/coroner [ME/C]) variables. We analyzed 1145 US autopsy reports from the years 2006-2020, inclusive, and considered decedent variables of age, ethnicity, height, weight, body mass index, toxicology, and mention of a conducted electrical weapon and ME/C influence variables of gender, country region, and year. We found that the homicide classification likelihood increased by a factor of 1.04-1.05 per year, 1.34-1.37 for a female medical examiner, and 1.4-1.5 going from Southern states to Western states. There is an increasing trend for ME/C to label nonfirearm ARDs as homicides in the United States. The homicide classification is more common in Western states and less common in Southern states, and it was more common with a female ME/C.

Femicide in the United States: A Study of Connecticut Autopsy and Death Investigation Data.

ABSTRACT: We examined the records of the Connecticut Office of the Chief Medical Examiner for all female homicides from 2012 to 2021 to ascertain the rate of femicide. The investigative data were subcategorized as femicides and nonfemicides. The records included autopsy, toxicology, and investigators' reports. All underwent autopsy examination. The relationship of the perpetrator, cause of death, and special circumstances were examined in conjunction with the United Nations operational criteria. If the death investigation did not identify the suspected perpetrator, news media were searched for a reported homicide or manslaughter arrest. The total number of homicides was 271, and 259 (96%) could be further categorized, of which 181 (70%) were femicides. Differences between the 2 cohorts included causes of death ( P 's < 0.001), age at death ( P < 0.001), and the involvement of murder-suicide ( P < 0.001). No differences were observed for race, and the yearly rate of femicides did not increase during the COVID-19 pandemic.

Surveillance for Unexplained Deaths of Possible Infectious Etiologies During the COVID-19 Pandemic-Minnesota, 2020-2021.

OBJECTIVES: Surveillance systems for unexplained deaths that might have an infectious etiology are rare. We examined the Minnesota Department of Health Unexplained Deaths and Critical Illnesses of Possible Infectious Etiology and Medical Examiner Infectious Deaths (UNEX/MED-X) surveillance system,-a system that expanded postmortem surveillance for infectious diseases during the COVID-19 pandemic by leveraging standard (medical examiner [ME]) and expanded (mortuary) surveillance to identify COVID-19-related deaths. METHODS: MEs, coroners, or morticians collected postmortem swabs from decedents with an infectious prodrome or with SARS-CoV-2 exposure before death but with no known recent infectious disease testing. The Minnesota Department of Health Public Health Laboratory used nucleic acid amplification, viral culture, and standard algorithms to test specimens collected postmortem for SARS-CoV-2, influenza virus, and other infectious pathogens. We reviewed UNEX/MED-X data from March 2, 2020, through December 31, 2021, and characterized decedents by location of swab collection (ie, ME or mortuary). RESULTS: From March 2, 2020, through December 31, 2021, the UNEX/MED-X surveillance system received samples from 182 decedents from mortuaries and 955 decedents from MEs. Mortuary decedents were older than ME decedents (median age, 78 vs 46 y). Seventy-three mortuary decedents (40.1%) and 197 ME decedents (20.6%) had SARS-CoV-2 detections. The UNEX/MED-X system identified 212 COVID-19-related deaths, representing 2.0% of total COVID-19-related deaths in Minnesota. Eighty-nine decedents (42.0%) were from racial and ethnic minority populations, representing 6.1% more COVID-19-related deaths among people from racial and ethnic minority populations than would have been detected without this surveillance system. PRACTICE IMPLICATIONS: Expanded and standard UNEX/MED-X surveillance builds capacity and flexibility for responding to emerging public health threats. Similar programs should be considered elsewhere as resources allow.

The National Association of Medical Examiners Position Paper on the Investigation and Certification of Pediatric Deaths From Environmental Neglect.

ABSTRACT: Pediatric deaths that occur because of environmental neglect often involve 4 common scenarios: (1) hyperthermia due to environmental exposure, (2) ingestion of an accessible drug or poison, (3) unwitnessed/unsupervised drownings, and (4) unsafe sleep practices. Given the same fact pattern, the manner of death will vary from accident to homicide to undetermined based on local custom and/or the certifier's training and experience. Medical examiner/coroner death certifications are administrative public health determinations made for vital statistical purposes. Because the manner of death is an opinion, it is understandable that manner determinations may vary among practitioners. No prosecutor, judge, or jury is bound by the opinions expressed on the death certificate. This position paper does not dictate how these deaths should be certified. Rather, it describes the challenges of the investigations and manner determinations in these deaths. It provides specific criteria that may improve consistency of certification. Because pediatric deaths often are of public interest, this paper provides the medical examiner/coroner with a professional overview of such manner determination issues to assist various stakeholders in understanding these challenges and variations.

A Series of 8 Illicit Fentanyl Intoxication Deaths in Infants and Toddlers.

ABSTRACT: We report 8 children younger than 2 years who died from acute illicit fentanyl intoxications in Connecticut between 2020 and 2022.The Connecticut Office of the Chief Medical Examiner (CT OCME) investigates all unexpected, violent, and suspicious deaths in Connecticut. The CT OCME's electronic database was searched for fentanyl deaths by age. All underwent autopsies and toxicology testing.The ages ranged from 28 days to 2 years (mean age, 12 months). The causes of death involved acute fentanyl intoxications with 1 having xylazine, 1 having para-fluorofentanyl, and 1 having cocaine and morphine. All the manners of death were certified as homicide. The postmortem fentanyl blood concentrations ranged from 0.40 to 46 ng/mL. Most of the children were found unresponsive after being put to sleep. Three were co-sleeping with adults (2 in bed; 1 on a recliner). There was a known history of parental/caregiver drug abuse in 7 of 8 of the fatalities.We summarize the key investigative, autopsy, and toxicological findings. As illicit fentanyl use increases, there is a potential for infant exposure and death. The investigation and certification of these deaths and the role of intentional administration versus inadvertent exposure due to caregiver neglect in the context of the certification of the manner of death are described.

See something, say something: the coroner's perspective.

The communicating safely policy, publicised by the catchphrase See Something, Say Something was released by the Medical Radiation Practice Board of Australia in 2019. It was developed to support medical radiation practitioners (MRPs) upholding the obligation to communicate urgent or unexpected findings in a timely manner, when identified on medical images. Prior to this policy being part of the professional capabilities, several untimely deaths occurred-the majority of whose causal factors could have been mitigated if imaging findings were urgently communicated by MRPs. This commentary summarises three coronial inquests that involved MRPs, discusses how these coronial findings are reflected in the communicating safely policy and provides some recommendations for the profession to ensure this policy is enacted in clinical practice.

Maternal Deaths Using Coroner's Data: A Latent Class Analysis.

OBJECTIVE: Knowledge regarding the antecedent clinical and social factors associated with maternal death around the time of pregnancy is limited. This study identified distinct subgroups of maternal deaths using population-based coroner's data, and that may inform ongoing preventative initiatives. METHODS: A detailed review of coroner's death files was performed for all of Ontario, Canada, where there is a single reporting mechanism for maternal deaths. Deaths in pregnancy, or within 365 days thereafter, were identified within the Office of the Chief Coroner for Ontario database, 2004-2020. Variables related to the social and clinical circumstances surrounding the deaths were abstracted in a standardized manner from each death file, including demographics, forensic information, nature and cause of death, and antecedent health and health care factors. These variables were then entered into a latent class analysis (LCA) to identify distinct types of deaths. RESULTS: Among 273 deaths identified in the study period, LCA optimally identified three distinct subgroups, namely, (1) in-hospital deaths arising during birth or soon thereafter (52.7% of the sample); (2) accidents and unforeseen obstetric complications also resulting in infant demise (26.3%); and (3) out-of-hospital suicides occurring postpartum (21.0%). Physical injury (22.0%) was the leading cause of death, followed by hemorrhage (16.8%) and overdose (13.3%). CONCLUSION: Peri-pregnancy maternal deaths can be classified into three distinct sub-types, with somewhat differing causes. These findings may enhance clinical and policy development aimed at reducing pregnancy mortality.

Opioid-related overdose deaths among people experiencing homelessness, 2017 to 2021: A population-based analysis using coroner and health administrative data from Ontario, Canada.

AIMS: To measure the change in proportion of opioid-related overdose deaths attributed to people experiencing homelessness and to compare the opioid-related fatalities between individuals experiencing homelessness and not experiencing homelessness at time of death. DESIGN, SETTING AND PARTICIPANTS: Population-based, time-trend analysis using coroner and health administrative databases from Ontario, Canada from 1 July 2017 and 30 June 2021. MEASUREMENTS: Quarterly proportion of opioid-related overdose deaths attributed to people experiencing homelessness. We also obtained socio-demographic and health characteristics of decedents, health-care encounters preceding death, substances directly contributing to death and circumstances surrounding deaths. FINDINGS: A total of 6644 individuals (median age = 40 years, interquartile range = 31-51; 74.1% male) experienced an accidental opioid-related overdose death, among whom 884 (13.3%) were identified as experiencing homelessness at the time of death. The quarterly proportion of opioid-related overdose deaths attributed to people experiencing homelessness increased from 7.2% (26/359) in July-September 2017 to 16.8% (97/578) by April-June 2021 (trend test P < 0.01). Compared with housed decedents, those experiencing homelessness were younger (61.3 versus 53.1% aged 25-44), had higher prevalence of mental health or substance use disorders (77.1 versus 67.1%) and more often visited hospitals (32.1 versus 24.5%) and emergency departments (82.6 versus 68.5%) in the year prior to death. Fentanyl and its analogues more often directly contributed to death among people experiencing homelessness (94.0 versus 81.4%), as did stimulants (67.4 versus 51.6%); in contrast, methadone was less often present (7.8 versus 12.4%). Individuals experiencing homelessness were more often in the presence of a bystander during the acute toxicity event that led to death (55.8 versus 49.7%); and where another individual was present, more often had a resuscitation attempted (61.7 versus 55.1%) or naloxone administered (41.2 versus 28.9%). CONCLUSIONS: People experiencing homelessness account for an increasing proportion of fatal opioid-related overdoses in Ontario, Canada, reaching nearly one in six such deaths in 2021.