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.

Development of an assessment technique for basic science retention using the NBME subject exam data.

INTRODUCTION: One of the challenges in medical education is effectively assessing basic science knowledge retention. National Board of Medical Examiners (NBME) clerkship subject exam performance is reflective of the basic science knowledge accrued during preclinical education. The aim of this study was to determine if students' retention of basic science knowledge during the clerkship years can be analyzed using a cognitive diagnostic assessment (CDA) of the NBME subject exam data. METHODS: We acquired a customized NBME item analysis report of our institution's pediatric clerkship subject exams for the period of 2017-2020 and developed a question-by-content Q-matrix by identifying skills necessary to master content. As a pilot study, students' content mastery in 12 major basic science content areas was analyzed using a CDA model called DINA (deterministic input, noisy "and" gate). RESULTS: The results allowed us to identify strong and weak basic science content areas for students in the pediatric clerkship. For example: "Reproductive systems" and "Skin and subcutaneous tissue" showed a student mastery of 83.8 ± 2.2% and 60.7 ± 3.2%, respectively. CONCLUSIONS: Our pilot study demonstrates how this new technique can be applicable in quantitatively measuring students' basic science knowledge retention during any clerkship. Combined data from all the clerkships will allow comparisons of specific content areas and identification of individual variations between different clerkships. In addition, the same technique can be used to analyze internal assessments thereby creating an opportunity for the longitudinal tracking of student performances. Detailed analyses like this can guide specific curricular changes and drive continuous quality improvement in the undergraduate medical school curriculum.

Accuracy of Medical Examiner's Assessment for Near-Real-Time Surveillance of Fatal Drug Overdoses, King County, Washington, March 2017-February 2018.

OBJECTIVES: Up-to-date information on the occurrence of drug overdose is critical to guide public health response. The objective of our study was to evaluate a near-real-time fatal drug overdose surveillance system to improve timeliness of drug overdose monitoring. METHODS: We analyzed data on deaths in the King County (Washington) Medical Examiner's Office (KCMEO) jurisdiction that occurred during March 1, 2017-February 28, 2018, and that had routine toxicology test results. Medical examiners (MEs) classified probable drug overdoses on the basis of information obtained through the death investigation and autopsy. We calculated sensitivity, positive predictive value, specificity, and negative predictive value of MEs' classification by using the final death certificate as the gold standard. RESULTS: KCMEO investigated 2480 deaths; 1389 underwent routine toxicology testing, and 361 were toxicologically confirmed drug overdoses from opioid, stimulant, or euphoric drugs. Sensitivity of the probable overdose classification was 83%, positive predictive value was 89%, specificity was 96%, and negative predictive value was 94%. Probable overdoses were classified a median of 1 day after the event, whereas the final death certificate confirming an overdose was received by KCMEO an average of 63 days after the event. CONCLUSIONS: King County MEs' probable overdose classification provides a near-real-time indicator of fatal drug overdoses, which can guide rapid local public health responses to the drug overdose epidemic.

Review of Coroner Inquest Recommendations into Opioid Prescribing Practices in Ontario: Ongoing Health Policy Gaps.

The rate at which opioids are being prescribed and the safety of prescription opioid use are serious and ongoing problems for individuals, communities and health systems across Canada. In 2011, a coroner's inquest was held in Brockville, Ontario, Canada, to examine the issue of prescription opioid diversion and abuse. Following the inquest, the jury provided 48 recommendations pertaining to prescribing and monitoring of opioids. The ensuing discussion highlights health policy gaps that remain to be addressed seven years after the inquest, in educational resource-sharing, high-dose prescribing, development and use of abuse-resistant formulations and coordination and monitoring of policy interventions.

Coroners court and directions to juries in Article 2 inquests.

Article 2 of the European Convention of Human Rights (ECHR) protects the Right to Life that is invoked in an inquest where the diseased has expired in circumstances of custody or control by an agency of state. The High Court in 2012 ordered the second inquest in the Hillsborough case where the correct directions to the jury were read as to when there is a breach of such a duty. The inquest findings resulted in criminal charges being brought against two former senior police officers, who were indicted linked to the disaster. This paper examines the inquest process where there is a jury and considers the framework of the Coroners Court in the context of Article 2 where death has occurred under circumstances of duress.

Interpretation of 'Unnatural Death' in Coronial Law: A Review of the English Legal Process of Decision Making, Statutory Interpretation, and Case Law.

The article examines the decision-making process for medical reporting of deaths to a coroner and the statutory basis for coronial decisions whether to investigate. It analyses what is published about the consistency of decision making of coroners and discusses what should be the legal basis for determining whether a particular death is natural or unnatural in English law. There is a review of English case law, including the significance of Touche and Benton and the development of 'unnatural' as a term of art, which informs what the courts have held to be an unnatural death. What case law indicates about multiple causes and the significance of the wording in the Coroners & Justice Act 2009 that triggers an investigation are considered. It highlights the importance of considering the medical cause of death and to what extent information other than the initial death report is required, before making the decision that the coroner's duty to open an investigation is triggered. The article concludes that a two-stage test is required. Firstly, is the cause of death medically unnatural? Secondly, whether the circumstances themselves are unnatural or such as to make a medically natural cause of death unnatural. If the coroner has reason to suspect the medical cause of death is unnatural per se the statutory duty to investigate will be engaged, regardless of the circumstances.

Late-life suicide in Asian people living in New Zealand: a qualitative study of coronial records.

BACKGROUND: There has been no previous study examining the phenomenon of suicide in older Asians in New Zealand. The aim of this study was to identify common factors and gain a better understanding of late-life suicide in Asian people living in New Zealand. METHODS: New Zealand Coronial Services provided records of all closed cases of late-life suicides (age ≥ 65 years) between July 2007 and December 2012. Out of the total of 225 cases, 15 were recorded as being of Asian ethnicity. These cases were reviewed in their entirety using a qualitative thematic analysis approach. RESULTS: Eight Asian men and seven Asian women completed suicide during this period. The majority (93%) lived with their families, and 80% were found by family after having completed suicide at home. Three main themes emerged from the thematic analysis: (i) suicide occurring in the context of a family; (ii) declining physical health; and (iii) a violent method of suicide. The role of the family has not been previously identified in other studies of late-life suicide in New Zealand. CONCLUSIONS: Further research is needed to identify ways Asian families can access culturally appropriate and accessible support and mental health services for their older members at risk of suicide. There is also a need for developing post-suicide interventions specifically for Asian families. The findings of this study have added to the growing evidence of declining physical health acting as a drive for late-life suicide.

[The coroner's autopsies in the Great Britain: the problems related to the quality of the studies, standardization, auditing, financial support and the approaches to their solution]. / Koronerskaia autopsiia v Velikobritanii: problemy kachestva issledovanii, standartizatsii, audita, finansirovaniia i puti ikh resheniia.

This article continues the series of previous publications of the authors based on the analysis of the detailed report of the experts of the National Confidential Enquiry into Patient Outcome and Death program (NCEPOD) designed to evaluate the quality of autopsies carried out by the coroners in the Great Britain. It was shown that only in 13 to 55% of the 1,691 case the operators had an opportunity to refer the necropsy materials for the pathological study. The problems encountered in association with histological and toxicological analysis arose from the misunderstanding between the coroners and the pathologists as regard the organizational aspects of autopsy studies as swell as the financial and economic considerations. The Coroner Rules that had been adopted in 1984 and remained in force in the country until 2005 needed to be radically revised, corrected, and amended to facilitate the solution of a number of problems and eliminate the formal organizational and technical contradictions that hampered the further improvement of the quality of autopsies that must be performed by the corners at the national rather than the local level. The maximum number of the unacceptable results were revealed in the protocols of autopsires carried out by the forensic medical experts. All pathologists in the Great Britain are recommended to pay special attention to all cases of sudden death of the adult subjects and the deceased epileptic patients. The detailed investigations are mandatory in all cases of death following medical manipulations, such as surgical interventions, and complications.

Health professionals' and coroners' views on less invasive perinatal and paediatric autopsy: a qualitative study.

OBJECTIVE: To assess health professionals' and coroners' attitudes towards non-minimally and minimally invasive autopsy in the perinatal and paediatric setting. METHODS: A qualitative study using semistructured interviews. Data were analysed thematically. RESULTS: Twenty-five health professionals (including perinatal/paediatric pathologists and anatomical pathology technologists, obstetricians, fetal medicine consultants and bereavement midwives, intensive care consultants and family liaison nurses, a consultant neonatologist and a paediatric radiologist) and four coroners participated. Participants viewed less invasive methods of autopsy as a positive development in prenatal and paediatric care that could increase autopsy rates. Several procedural and psychological benefits were highlighted including improved diagnostic accuracy in some circumstances, potential for faster turnaround times, parental familiarity with imaging and laparoscopic approaches, and benefits to parents and faith groups who object to invasive approaches. Concerns around the limitations of the technology such not reaching the same levels of certainty as full autopsy, unsuitability of imaging in certain circumstances, the potential for missing a diagnosis (or misdiagnosis) and de-skilling the workforce were identified. Finally, a number of implementation issues were raised including skills and training requirements for pathologists and radiologists, access to scanning equipment, required computational infrastructure, need for a multidisciplinary approach to interpret results, cost implications, equity of access and acceptance from health professionals and hospital managers. CONCLUSION: Health professionals and coroners viewed less invasive autopsy as a positive development in perinatal and paediatric care. However, to inform implementation a detailed health economic analysis and further exploration of parental views, particularly in different religious groups, are required.

Farm suicides in New Zealand, 2007-2015: A review of coroners' records.

OBJECTIVE: Economic recessions and severe weather events are often associated with increased suicide rates. The Global Dairy Crisis 2015/2016 led to an economic downturn in the New Zealand dairy farming industry and, coupled with droughts in some regions and floods in others, raised fears about increased suicide rates among farmers. However, little was known about suicides in the farming sector. This study reviews characteristics of recent farm-related suicides in New Zealand and assesses the extent to which financial stresses contributed to the deaths. METHODS: Data were abstracted from coroners' records for a consecutive series of 185 people in farm- and agriculture-related occupations who died by suicide between 2007 and 2015 and for whom coronial inquiries had been completed. RESULTS: Farm suicides were heterogeneous: six distinct risk profiles were identified. Financial stresses made negligible contributions to farm suicides. Overall, risk factors for farm suicides differed little from risk factors for suicide in the general population. However, suicide risk in farmers was exacerbated by ready access to firearms: almost 40% of farm suicides involved firearms, compared to 8% in the general population over the same time. Among farm suicides, young male farm labourers predominated, rather than farm owners or managers. For many young men, relationship losses, acute alcohol intoxication and ready access to a firearm formed a common constellation of risk factors. CONCLUSIONS: While coroners' records are variable and do not record specific information about financial stresses and weather events, it was clear that these issues made a negligible contribution to farm suicides. A range of rural suicide prevention initiatives are needed to address various farm suicide risk profiles. In particular, young male labourers often had no contact with health services prior to death, suggesting that rural suicide prevention efforts need to be positioned within community, farming and sports organisations, as well as health and social service providers.

Valoración médico legal del consumo de la marihuana sintética / Legal medical evaluation of the consumption of synthetic marihuana

ResumenLa marihuana sintética es una sustancia que ha incrementado su consumo en los últimos años y que conlleva a múltiples implicaciones en la salud de las personas que la utilizan. Este artículo se basa en identificar los principales formas de uso, los síntomas de los evaluados, la fisiopatología de estas sustancias y los riesgos y consideraciones para el manejo de pacientes que consumen cannabinoides sintéticos, así como los criterios Médico Legales que se deben tener presentes en el momento de realizar una valoración de evaluados que utilizan alguna sustancia en la Clínica Médico Forense y en el momento de realizar una autopsia Médico Legal en particular cuando existe la historia reciente del consumo de la marihuana sintética.

SummarySynthetic marijuana is a substance that has increased its consumption in recent years and that leads to multiple implications on the health of people who use it. This article is based on identifying the main forms of use, the symptoms of the evaluated ones, the pathophysiology of these substances and the risks and considerations for the management of patients who use synthetic cannabinoids, as well as the Legal Medical criteria that must be kept in mind The time to make an assessment in the Forensic Medical Clinic and at the time of performing a Medical Legal autopsy in particular when there is the recent history of the consumption of synthetic marijuana

[The coroner's autopsies in the Great Britain: the problems related to the quality of the studies, standardization, auditing, financial support and the approaches to their solution (part 2)]. / Koronerskaia autopsiia v Velikobritanii: problemy kachestva issledovanii, standartizatsii, audita, finansirovaniia i puti ikh resheniia (chast' 2).

This article extends the previous publication of the authors based on the analysis of the detailed report of the experts of the National Confidential Enquiry into Patient Outcome and Death program (NCEPOD) issued in the Great Britain in 2006. The analysis has demonstrated that all autopsy studies should invariably involve measurement of the corpse length and weight (including body mass index) as well as the detailed description of all injuries to the body (or references to their absence). All autopsy studies should be carried out only by a medical professional (e.g. a pathologist, histologist, forensic medical expert, etc.). The thorough examination of the cadaver is mandatory prior to evisceration. The maximum scope of the examination of all body cavities with the comprehensive description of all internal organs and systems is compulsory. Putrefaction and decomposition of the corpse can not be regarded as a justification for its perfunctory ('restricted') inspection; on the contrary, these dictate the necessity of a more careful examination with the compulsory description of all organs and body systems as well as harvesting biological fluids and tissues for the laboratory analyses (including histological, toxicological, and other relevant studies).

Department of Health consultation on medical examiners and death certification reforms: A commentary on the criteria for notification to be laid down in regulation.

The Department of Health has completed its consultation on the nature of the new medical examiner system and supporting regulations. This article considers whether the regulations for death notification to coroners are fit for purpose in the light of the medical literature on unnatural deaths and the experience of a coroner in a jurisdiction with a heavy workload from specialist hospital referrals. It concludes that they are to be welcomed, but that they should not rely on natural/unnatural death as a criterion for notification of deaths during the course of medical treatment, or refer to 'neglect'. Furthermore, they should ensure that sudden-death syndromes, which may be considered by doctors as natural, are still notified. Relying on these changes to reduce coronial investigations would be unwise. If that is the intention, other reforms may be necessary.

[The coroner's autopsies in the Great Britain: the problems related to the quality of the studies, standardization, auditing, financial support and the approaches to their solution]. / Koronerskaia autopsiia v Velikobritanii: problemy kachestva issledovanii, standartizatsii, audita, finansirovaniia i puti ikh resheniia.

The objective of the present study was to analyze the experience of the coroners and pathologists in the Great Britain based on the results of the coroner's autopsies and recommendations of the experts involved in the activities carried out in the framework of the National Confidential Enquiry into Patient Outcome and Death program (NCEPOD). The recommendations are designed to reform the country's medical examiner system, improve the equipment of the mortuary facilities, and optimize funding for the autopsy studies. The authors consider in the chronological order the following issues of the coroners and pathologists' activities: organization of their work and its procedural aspects, ordering coroner's autopsies, preparation for their performance, analysis of the relevant documentation (autopsy reports) and medical case histories (discharge summaries). Also discussed are the recommendations of the NCEPOD experts for the improvement of the said studies with the detailed analysis of the causes underlying the aforementioned problems and concise comments of the authors.

Contradictory coroners? Decision-making in death investigations.

AIM: National coroner data demonstrate differences in the rates at which coroners across England and Wales choose to investigate reported deaths and the frequency by which they record certain conclusions. This study sought to examine how decisions are made by coroners and whether they differed when faced with identical case information. METHODS: Three different clinical scenarios were circulated via a web link to all senior coroners. The case information was contained within a 'Decision Board' displayed on screen. Each scenario had nine consistent categories of information, such as the cause of death and the medical history. Participants were asked to indicate an inquest conclusion (verdict) using free text and to provide comments. The way in which participants accessed the case information (order, frequency, etc) was recorded by the computer software. RESULTS: 35 coroners responded. There was little consensus as to conclusion with scenarios 1 and 2 generating four different outcomes and scenario 3 generating an extraordinary eight different conclusions among respondents. Despite coming to widely different conclusions, coroners demonstrated very similar decision-making processes. Conclusions were robustly defended yet proffered alternatives were plentiful. The comments made indicated a difference in the personal attitudes of coroners towards case information. CONCLUSIONS: Different coroners faced with identical case information arrived at widely different case outcomes ranging from no further investigation to finding numerous alternative verdicts. Disparity appeared to be a product of differing personal attitudes among coroners. National coroner consensus to achieve a shared inference from available evidence is urgently needed.

The Value of Outsourcing Selected Cases in a Medical Examiner Population: A 10-Year Experience.

Due to increasing caseloads and inadequate staffing, the burden on Coroner/Medical Examiner Offices to comply with recommended autopsy limits for forensic pathologists (FPs) has been difficult. Since 2006, pathologists at the University of Alabama at Birmingham have performed select autopsies for the Alabama Department of Forensic Sciences. Each case was reviewed by a state FP and scene investigator to determine appropriateness for referral. All referred cases received full postmortem examination including microscopic examination and collection of toxicological samples, and toxicology was ordered by the referring FP as appropriate. The final cause and manner of death were determined by the referring state FP after review of all findings. A majority of the 421 cases were ruled accidental deaths (233), most due to drug toxicity. Of the 178 natural deaths, 118 were attributed to cardiovascular disease. Outsourcing select forensic cases can be educational and an effective tool to manage workflow without compromising quality.

Medicolegal Death Investigation and Hospital Patient Safety and Quality Outcomes: A Naturally Synergistic Collaboration.

The role of medicolegal death investigation (MLDI) systems in the assessment of violent deaths (e.g., gunshots, stab wounds, car crashes) is well known. However, the role of MLDI systems in informing healthcare agencies about potential patient safety and quality improvement activities is less understood and thus the main focus of this article. In this article we describes-one agency's initiatives to identify decedents whose circumstances or cause of death had potential relevance for patient safety and quality outcomes and to communicate those findings to acute care hospitals where the decedents were previously treated. We also describes the evaluation of this communication process and provide preliminary outcomes of these efforts.

Skeletal Indicators of Stress: A Component of the Biocultural Profile of Undocumented Migrants in Southern Arizona.

The ability of forensic anthropologists in the United States to distinguish the remains of foreign nationals from those of American citizens may be crucial to the identification process. This study adds new criteria for identifying Hispanic foreign nationals in southern Arizona to those previously outlined by Birkby et al. (J Forensic Sci 53, 2008, 29) in the "cultural profile." Skeletal indicators of nonspecific stress were evaluated in undocumented border crossers (UBCs) at the Pima County Office of the Medical Examiner and in documented American samples. Odds ratios show significant associations between UBC status and the presence of porotic hyperostosis and enamel hypoplasias, which are, respectively, 7.9 and 3 times more prevalent among UBCs. These findings are consistent with disparities in access to adequate nutrition and health care during childhood. In conjunction with context and other biocultural factors, the presence of these conditions should prompt practitioners to consider that unidentified remains may represent foreign nationals.

Characteristics of people dying by suicide after job loss, financial difficulties and other economic stressors during a period of recession (2010-2011): A review of coroners׳ records.

BACKGROUND: Suicide rates increase during periods of economic recession, but little is known about the characteristics of people whose deaths are related to recession, the timing of risk in relation to job loss, the nature of financial stresses and the sources of help individuals used. METHODS: We extracted information on social and economic circumstances, mental health and help-seeking from the coroners׳ records of 286 people who died by suicide in 2010 and 2011 in four areas of England. We graded each death on a 5-point scale of 'recession-relatedness', measuring the extent to which recession, employment and financial problems contributed to the death. RESULTS: Financial and employment-related issues contributed substantially to 38 (13%) of the deaths and were thought to be the key contributing factor in 11 (4%). Individuals whose deaths were thought to be related to the recession were less likely to have previously self-harmed but were more likely to be employed (61% vs. 43%), have financial difficulties (76% vs. 23%) and financial dependents (55% vs. 23%). Amongst the subset of 11 people where financial/employment issues were the key contributory factor, only two (18%) had ever had contact with psychiatric services. LIMITATIONS: Details on finances and employment were not systematically recorded by coroners. We found richer information was usually available for people who were living with other people. CONCLUSIONS: Financial difficulties, little past psychiatric history, low levels of service contact and having financial dependents were more common in 'recession-related' deaths. This suggests that interventions to prevent recession-related rises in suicide should be focused on non-clinical agencies and initiatives.