BRCA1 and BRCA2 carriers with breast, ovarian and prostate cancer demonstrate a different pattern of metastatic disease compared with non-carriers: results from a rapid autopsy programme.

AIM: To catalogue and compare the pattern of metastatic disease in germline BRCA1/2 pathogenic mutation carriers and non-carriers with breast, ovarian and prostate cancer from a rapid autopsy programme. METHODS AND RESULTS: The number of metastases in the major body systems and the proportion of participants with metastases were documented in 50 participants (19 germline mutation carriers). Analysis was conducted on the participants' pattern of disease for the different cancers and mutation subgroups. The four commonly affected organ systems were the digestive (liver only) (82%), respiratory (76%), gastrointestinal (65%) and reticuloendothelial (42%). There were significant differences in the pattern of metastatic breast cancer in BRCA1/2 germline carriers compared with non-carriers. Breast cancer carriers had significantly fewer organ systems involved (median n = 3, range = 1-3) compared with non-carriers (median n = 9, range = 1-7) (P = 0.03). BRCA1/2 carriers with ovarian carcinomas had significantly more organ systems with metastatic carcinoma (median n = 10, range = 3-8) than non-carriers (median n = 5, range = 3-5) (P < 0.001). There were no significant differences in the number of involved systems in BRCA2 carriers compared with non-carriers with prostate cancer (P = 1.0). There was an absence of locoregional disease (6.5%) compared with distant disease (93.5%) among the three cancer subtypes (P < 0.001). The majority of metastatic deposits (97%) collected during the autopsy were identified by recent diagnostic imaging. CONCLUSION: Even though a major limitation of this study is that our numbers are small, especially in the breast cancer carrier group, the metastatic patterns of breast and ovarian cancers may be impacted by BRCA1/2 carrier status, suggesting that tumours derived from patients with these mutations use different mechanisms of dissemination. The findings may focus clinical diagnostic imaging for monitoring metastases where whole-body imaging resources are scant.

Legislating the Cause of Death: "What's in a Name ".

In recent years legal rules to regulate causes of death have begun to appear. One example of this relates to the term "excited delirium" which has been subject to challenge by medical and legal professionals. Human rights activists have pushed against its usage by law enforcement and medical death investigators. The passing of the California Assembly Bill 360 restricting the use of the term is an example of this. Legislatively mandating, or banning causes of death poses an interesting challenge for death investigators. The lack of uniform guidance on how deaths should be classified across different jurisdictions and the variations in linguistic and causation-based language in cause of death statements may have influenced this development. Legislation that seeks to enforce ways of documenting the cause of a death, which is in effect an expert medical opinion, presents significant future challenges in expert testimony.

Thunderstorm asthma in seasonal allergic rhinitis: The TAISAR study.

BACKGROUND: Asthma epidemics associated with thunderstorms have had catastrophic effects on individuals and emergency services. Seasonal allergic rhinitis (SAR) is present in the vast majority of people who develop thunderstorm asthma (TA), but there is little evidence regarding risk factors for TA among the SAR population. OBJECTIVE: We sought to identify risk factors for a history of TA and hospital presentation in a cohort of individuals with SAR. METHODS: This multicenter study recruited adults from Melbourne, Australia, with a past diagnosis of TA and/or self-reported SAR. Clinical information, spirometry results, white blood cell count, ryegrass pollen-specific (RGP-sp) IgE concentration, and fractional exhaled nitric oxide were measured to identify risk factors for a history of TA in individuals with SAR. RESULTS: From a total of 228 individuals with SAR, 35% (80 of 228) reported SAR only (the I-SAR group), 37% (84 of 228) reported TA symptoms but had not attended hospital for treatment (the O-TA group), and 28% (64 of 228) had presented to the hospital for TA (the H-TA group). All patients in the H-TA group reported a previous asthma diagnosis. Logistic regression analysis of factors associated with O-TA and H-TA indicated that lower FEV1 value and an Asthma Control Questionnaire score higher than 1.5 were associated with H-TA. Higher blood RGP-sp IgE concentration, eosinophil counts, and fractional exhaled nitric oxide level were significantly associated with both O-TA and H-TA. Receiver operating curve analysis showed an RGP-sp IgE concentration higher than 10.1 kU/L and a prebronchodilator FEV1 value of 90% or lower to be biomarkers of increased H-TA risk. CONCLUSION: Clinical tests can identify risk of a history of TA in individuals with SAR and thereby inform patient-specific treatment recommendations.

Independent Death Investigation - The Challenge: The Report to the United Nations Human Rights Council of the Special Rapporteur on Extra-judicial, Summary of Arbitrary Executions.

Around the world, death investigation takes place utilising a variety of medical, scientific, administrative and legal systems that are specific to the particular legal jurisdiction within which the death occurred. While an internationally agreed approach might be desirable, in practice the vicissitudes of the political, legal, educational and fiscal environments of different nations mean that there are considerable challenges to the notion of "independence" when it comes to determining how and why a person died. In his recent report the Special Rapporteur on extra-judicial, summary or arbitrary executions outlined the initial results of his ongoing review into the challenges faced by medico-legal death investigators when attempting to uncover the cause and manner of potentially unlawful deaths and highlights some of the features of death investigation systems that limit the successful discharge of this duty.

Killing of Elderly Patients by Health Care Professionals: Insights From Coroners' Inquests and Inquiries in Three Cases.

As the world's population ages, a question of who can be trusted to look after the increasing elderly population arises. Health care professionals are commonly considered one of the group of people we entrust with our health care and maintenance of a good quality of life. Unfortunately, some abuse this trust. Harold Shipman, Elizabeth Wettlaufer and Roger Dean are three examples of health care professionals held responsible for multiple homicides of patients aged 65 years and older in their care. Harold Shipman, a United Kingdom doctor, is suspected of killing potentially 400 patients over 27 years. However, the true number may never be known. Elizabeth Wettlaufer, a Canadian nurse, admitted to killing eight patients over seven years and Roger Dean, an Australian nurse, killed 11 patients in one night by deliberately lighting a fire in a health care facility. The subsequent inquiry reports into their actions resulted in multiple recommendations which aimed to prevent similar occurrences and to protect the lives of this vulnerable cohort of people. These recommendations included restrictions on the hiring process of health care professionals and increasing the accountability of access to Schedule Eight drugs by doctors and registered nurses. The governments responsible for responding to the inquiry reports have done so in various ways, although not all recommendations have been implemented and some may not be practical with current residential care infrastructure provisions and requirements. More work is required to determine the types of countermeasures that could be implemented to protect the elderly from maverick health care professionals.

COVID-19 and Forensic Medical Practice.

The COVID-19 pandemic has affected the community in multiple ways. These include direct health impacts on those infected and indirect health impacts on others who may, through fear of infection, not avail themselves of available "face-to-face" health care services. The impact of COVID-19 on the legal system and the related medico-legal services it relies upon has received less attention but the ongoing social restrictions put in place because of the pandemic have the capacity to disrupt a range of legal processes. The impact of the pandemic has the capacity to interfere with both forensic medical and legal processes both in the short term and the long term. It may take some time for the potential harms to be realised but as the pandemic gradually comes under control from a public health perspective the interference to criminal and civil justice will start to become more visible.

The Role of Patient-reported Outcome Measures in Post-operative Death Investigations.

Coronial investigations of post-operative deaths can play an important role in improving the quality and safety of patient care. Correctly identifying reportable deaths in the post-operative period and reporting them to the coroner is a key responsibility of medical practitioners but may be challenging, particularly when determination of unexpectedness is problematic. Patient-reported outcome measures (PROMs) have a potential role to play in assisting clinicians with better identification of these reportable deaths. Moreover, the inclusion of PROMs within coronial investigations can assist in identifying systemic failures and result in recommendations on public health and safety. In particular, PROMs could be effective in addressing the overuse of surgery which remains a major public health concern. While the role of PROMs in clinical practice has undergone extensive research, their potential use in death investigations has been overlooked. As medicine continues to transition towards a patient-centred model of care, the use of frameworks such as PROMs will become increasingly important and may also provide benefit to the process of medicolegal death investigations.

Difference in the characteristics of mortality reports during a heatwave period: retrospective analysis comparing deaths during a heatwave in January 2014 with the same period a year earlier.

OBJECTIVES: To describe the characteristics of deaths reported to the Coroners Court of Victoria (CCOV) during Victoria's last heatwave (14-17 January 2014) and subsequent 4 days (18-21 January) using medicolegal data obtained from both the police investigation report and the pathologist's report. DESIGN, SETTING AND PARTICIPANTS: A single-jurisdiction population-based retrospective analysis of consecutive heat-related deaths (HRDs) reported to the CCOV between 14 and 21 January 2014 with a historical comparison group. MAIN OUTCOME MEASURES: Descriptive statistics were used to summarise case demographics, causes of death and the types of investigations performed. The cases from 2014 were subgrouped into HRD and non-HRD. RESULTS: Of the 222 cases during the study period in 2014, 94 (42.3%) were HRDs and 128 (57.7%) were non-HRDs. HRDs were significantly older than non-HRDs (70.5 years: SD=13.8 vs 61.0 years: SD=22.4, t(220)=3.60, p<0.001, 95% CI 4.3 to 14.6). The most common primary cause of death in HRDs was circulatory system disease (n=57, 60.6%), which was significantly higher when compared with non-HRDs (n=39, 30.5%; χ2=20.1, p<0.001, OR 3.5, 95% CI 2.0 to 6.2). HRDs required significantly greater toxicology investigation (89.4% (n=84) vs 71.9% (n=92); χ2=10.9, p<0.001, OR 3.3, 95% CI 1.54 to 7.03) and greater vitreous biochemistry testing (40.4% (n=38) vs 16.4% (n=21); χ2=16.0, p<0.001, OR 3.5, 95% CI 1.9 to 6.5). CONCLUSIONS: A heatwave places a significant burden on death investigation services. The inclusion of additional laboratory tests and more detailed circumstantial information are essential if the factors that contribute to HRDs are to be identified.

Sudden natural death behind the wheel: Review of driver deaths and fitness to drive assessment history in Victoria, Australia 2012-2013.

This study reviews the circumstances and medical causes of death of motor vehicle drivers who died in circumstances of sudden illness whilst behind the wheel in Victoria, Australia 2012-13. The driver's fitness to drive assessment history was also examined to identify prevention opportunities. Deaths included in the study were those referred to a panel responsible for determining whether the driver fatality should be included in the official road toll, where prior doubt exists. A research team comprising of forensic physicians examined the case file of each death involving sudden illness. Forty-five driver deaths during the two-year period were reviewed. Ischaemic heart disease was the most common cause of death. Over 80% of drivers were male with a median age of 64 years. While limited medical history was available, significantly impacting study analysis, findings identified minimal opportunity to improve the fitness to drive review process.

Neglect in Aged Care - A Role for the Justice System?

The Royal Commission into Aged Care Quality and Safety's Interim Report entitled Neglect, identified multiple failings in meeting Australia's care needs of older people. Many of these have been examined from both health and regulation-based perspectives. However, although some of the issues uncovered relate to potential criminal acts, relatively few prosecutions of individuals for abuse in aged care contexts take place. In addition to the social invisibility of the aged in our community investigators may experience considerable difficulties in utilising traditional processes for criminal investigation and prosecution in matters involving aged care institutions.

Variations in death notification of nursing home residents to Australian Coroners.

OBJECTIVES: To examine the impact of changes to the reporting requirements in coronial legislation on the nature and frequency of nursing home resident deaths reported to Coroners. DESIGN: National retrospective study of a population cohort of nursing home resident deaths. SETTING: Accredited Australian nursing homes between July 2000 and June 2013. PARTICIPANTS: Residents who died in nursing homes accredited by the Aged Care Standards and Accreditation Agency reported to Coroners. MAIN OUTCOME MEASURES: We explored three death-reporting models in the nursing home setting: comprehensive model, selective 'mechanism of death' model and selective 'age of death' model. These models were examined by manner of death subgroups: natural, falls-related and other external causes using the outcome measure of deaths notified to the Coroner per 1000 residents. We used an interrupted time series analysis using generalised linear regression with a negative binomial probability distribution and a log link function. RESULTS: The comprehensive model showed the proportion of reportable deaths due to natural causes far exceeded those from falls and other external cause. In contrast, the selective notification models reduced the total number of reportable deaths. Similarly, the selective 'age of death' model showed a decline in the reportable external cause deaths. CONCLUSIONS: Variation in the causes, locations and ages of persons whose deaths are legally required to be notified to Coroners impacts the frequency and nature of deaths of nursing home residents investigated by Coroners. This demonstrates that legislation needs to be carefully framed and applied to ensure that the prevention mandate of Coroners in Australia is to be achieved.

The Investigations into What Happened at the Gosport War Memorial Hospital - Did the Coroner's Process Help?

The Gosport Independent Panel was established to review the care of older patients at the Gosport War Memorial Hospital in England over some 20 years. There had been a number of internal and external investigations that included police investigations, clinical care audits, GMC investigations and inquests. The Panel provided a means of public disclosure of much of the contents of the prior investigations and resulted in the creation of a catalogue of all relevant information. The report indicated that many of the investigative processes had failed to address the concerns of family and staff. In part this appears to have been the result of some investigations being limited in their ability to deal with social and community concerns and focusing on whether criminal prosecutions should be brought. Legislative restrictions regarding the nature and outcomes of the inquest process in the United Kingdom compounded these concerns. It is interesting to speculate whether a more proactive inquest system brought into play earlier might have alleviated many of the community and professional concerns regarding patient care.

Geriatric Forensic Medicine - A Specialty that can no Longer Wait to be Realised.

The rise in the population and the growth in the proportion of the elderly in our population are changing the structure of many of our communities and placing increasing demands on our social and health care services. "Scandals" regarding conditions and standards of care in residential aged care facilities have raised concerns about the regulation, assessment and auditing of these community services for the elderly. At the same time longer working lives change the age factors related to employment opportunities and the cadre of older employees presents a different range of human resource issues and occupational health and safety problems for employers. While there is evidence that an older workforce can bring a wider experience and understanding of critical issues to many work disciplines, ageing practitioners may pose professional regulatory issues for the community when considerations of cognitive and technical/physical ability arise. It is in these settings that the need for a forensic focus on gerontology and medical geriatrics arises.

Policy Development and Regulation of Aged Care.

Data from both medical and legal investigation can provide significant opportunities for legal and regulatory policy development that in some sectors are often ignored or missed. The provision of safe and high-quality care for the vulnerable, frail older people who live in residential aged care services (often termed nursing homes) in Australia continues to come under enormous scrutiny. The year 2017 saw a plethora of inquiries, some concluded and others ongoing, investigating the safety and care provided to residents. These inquiries have ramifications for the collection and use of data in the development of policy and regulation aimed at improving care within the aged care sector.

Frequency and nature of coroners' recommendations from injury-related deaths among nursing home residents: a retrospective national cross-sectional study.

BACKGROUND: Coroners are tasked with the investigation of unnatural and unexpected deaths. In Australia, the coroner's role also includes making recommendations for promoting interventions to improve public safety. However, the coroners' role in public health and safety in the aged care setting is an underexplored area of research. OBJECTIVES: To describe the frequency and nature of coroners' recommendations for prevention of harm from injury-related deaths among nursing home residents in Australia. SETTING: Accredited nursing homes in Australia. SUBJECTS: Nursing home residents whose deaths resulted from external causes occurring between 1 July 2000 and 31 December 2013 and notified to a coroner. MEASUREMENTS: Coroners' recommendations were identified and extracted from the National Coronial Information System. Descriptive statistical techniques were used to calculate the frequency and proportion of recommendations made. The nature of recommendations was quantified using a method comprising seven elements derived from internationally accepted and applied public health conceptual models of mortality causation and prevention. RESULTS: Coroners made recommendations about the prevention of harm in 53 of the 3289 (1.6%) external cause deaths of nursing home residents. Recommendations were most frequently made for deaths resulting from falls; however, the rate of recommendations per 1000 deaths was highest for thermal mechanisms and complications of clinical care. Most recommendations described the 'countermeasure' element, but rarely specified a timeframe for implementation. CONCLUSION: Coroners' recommendations need to be further enhanced in the age care setting. The development of national and international guidelines on best practice in the formulation of effective recommendations should be undertaken.

Premature deaths of nursing home residents: an epidemiological analysis.

OBJECTIVES: To conduct a descriptive epidemiological analysis of external cause deaths (premature, usually injury-related, and potentially preventable) of nursing home residents in Australia. DESIGN: Retrospective study of a cohort of nursing home residents, using coronial data routinely recorded by the National Coronial Information System. SETTING AND PARTICIPANTS: Residents of accredited Australian nursing homes, whose deaths were reported to coroners between 1 July 2000 and 30 June 2013, and determined to have resulted from external causes. MAIN OUTCOME MEASURES: Causes of death, analysed by sex and age group, and by location of incidents leading to death and location of death. Rates of death were estimated on the basis of Australian Bureau of Statistics population and Australian Institute of Health and Welfare nursing home data. RESULTS: Of 21672 deaths of nursing home residents, 3289 (15.2%) resulted from external causes. The most frequent mechanisms of death were falls (2679 cases, 81.5%), choking (261 cases, 7.9%) and suicide (146 cases, 4.4%). The incidents leading to death usually occurred in the nursing home (95.8%), but the deaths more frequently occurred outside the nursing home (67.1%). The annual number of external cause deaths in nursing homes increased during the study period (from 1.2 per 1000 admissions in 2001-02 to 5.3 per 1000 admissions in 2011-12). CONCLUSION: The incidence of premature and potentially preventable deaths of nursing home residents has increased over the past decade. A national policy framework is needed to reduce the incidence of premature deaths among Australians living in nursing homes.

Mortality in Nursing Homes Following Emergency Evacuation: A Systematic Review.

OBJECTIVES: To determine the risk associated with mortality among nursing home residents within 6 months following an evacuation because of man-made or natural disasters. DESIGN: A systematic review conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Statement. SETTING: All peer-reviewed studies published in English, French, German, or Spanish between January 1, 2000 and December 31, 2015, examining mortality within 6 months of disaster evacuation from a nursing home. MEASUREMENTS: Extracted information included study and population characteristics, mortality measures, and risk factors. Studies were examined using the disaster management cycle that considers preparedness, response, recovery, and mitigation. RESULTS: The 10 included studies were published between 2010 and 2015 with one-half conducted in the United States. Only 3 studies detailed the preparedness stage, and 4 detailed the response stage of the disaster management cycle. Mortality was measured as an indicator of recovery and was found to be elevated at 1 month [from 0.03% (n = 1088) to 10.5% (n = 75)] 3 months [from 0.08% (n = 3091) to 15.2% (n = 197)], and 6 months [from 14.9% (n = 263) and 16.8% (n = 22)] postevacuation compared with pre-evacuation and sheltering-in-place. Studies identified vulnerable residents as being over 80 years of age, frail, dependent, male residents with multiple comorbidities and, made recommendations on disaster preparedness. CONCLUSIONS: There is little research on the effects of evacuation on nursing home residents, which is surprising considering the elevated risk of mortality postevacuation. Evacuation seems to have a negative effect on the survival of nursing home residents independent of the effect of the disaster. Standard evacuation procedures may be less applicable to this vulnerable population because of extra challenges they face in disasters.