The prevalence of drugs in carbon monoxide-related deaths: a retrospective study, 2000-2003

The objective of this study was to review demographic characteristics and drugs detected in carbon monoxide (CO)-related deaths from cases received by the Office of the Cuyahoga County Coroner in Cleveland, Ohio, from 2000-2003. Postmortem reports were reviewed, and decedents for which CO was listed as the cause of death were included. The data were compiled into 3 groups according to the official coroner's verdict as to the manner of death: accident, suicide, and homicide. Included in this study were 122 cases: 84 (69%) accidental, 31 (25%) suicide, and 7 (6%) homicide. Accident decedents were typically white males, aged 40-59 years, residing in Cleveland. Suicide decedents were also middle-aged, white males but residing in the suburbs. Homicide decedents under the age of 6 were characteristically black (N=2), while decedents over the age of 39 were predominately white (N=3). Carboxyhemoglobin (COHb) levels in suicide cases were higher than concentrations measured in accidental deaths. The highest percentage of suicide decedents (36%) had a COHb level>70% saturation, accident decedents (36%) between 50% and 69% saturation, and homicide decedents (71%) below 50% saturation. Ethanol (N=34) was detected in 28% of deaths, and therapeutic and/or abused drugs (N=50) were detected in 41% of deaths. Illicit drugs were detected in 11% of cases (cocaine/metabolites; THC/metabolites), other drug positives were therapeutic medications. The most common drugs detected were antidepressants and antihistamines in suicides and pain medications and antihistamines in accidents.     

A study of drug detection in a postmortem pediatric population

At The Office of the Cuyahoga County Coroner (CCCO), Cleveland, Ohio, it is customary to perform an autopsy and conduct toxicological testing on decedents less than 19 years of age. This study provides a retrospective evaluation of drugs detected in a pediatric postmortem population between the years 1998 and 2002 (n = 730). Demographic information, cause and manner of death, and toxicological results were examined. Blacks comprised 54% of cases, males 59%, and 48% were less than one year of age or stillborn. Forty-two percent of deaths were ruled natural, 27% accident, 13% undetermined, 5% suicide, and 2% homicide. Of the 640 cases subjected to comprehensive testing, 38% of the cases were positive for at least one compound. Resuscitative/treatment drugs were detected most frequently (56% of positive results), followed by illicit drugs (26%), ethanol (11%), carbon monoxide (8%), and antihistamines (6%). Eighty-seven cases contained more than one drug. The deaths of 47 individuals were drug related (6%). In this population, it is recommended that illicit drugs and ethanol are targeted for testing, especially when limited specimens are available for analysis.     

Gunshot fatalities in children and adolescents in New York City

We reviewed the case records of all fatalities due to gunshot wounds in children and adolescents under 19 years of age in New York City from 1996 to 2000. The epidemiological profile, circumstances, toxicology results, location, and injuries were examined. There were 263 deaths: 242 homicides, 17 suicides, and 4 accidents. Among the homicides, 96% involved Black or Hispanic and 68% involved 17 and 18-year-old decedents. There were 11 times as many male as female homicides. The detection of ethanol and/or illicit drugs was 56% in the homicide and 53% in the suicide groups. Suicide notes were found in 18% of suicides, and an additional 35% verbally expressed a plan to commit suicide. Most suicides (77%) were in the home and half of the homicides occurred on the street.     

Adolescent death: a 15-year retrospective review

Adolescents comprise an eclectic mix of people vitally important to society yet long-term comprehensive studies on the circumstances of their deaths are lacking in the pediatric forensic literature. The authors reviewed all forensic cases referred to the Medical University of South Carolina Forensic Pathology section over the fifteen years between January 1989 and December 2003. In accordance with the World Health Organization (WHO) definition of adolescents, only decedents 10-19 years of age were included. The authors examined the cause and manner of death, age, gender, and race of the victims in all cases. The toxicology results, perpetrator, death scenario and location, and victim traits were analyzed when available. For all adolescents, the most common manner of death was accident followed by homicide, suicide, natural, and undetermined. Within the adolescent population two distinct groups, 10-14 years old and 15-19 years old, were identified. Though both groups were similar in that they experienced a high number of accidental deaths, decedents of older age group suffered a higher percentage of violent deaths while decedents of the younger group were more likely to die of natural causes. Many of the accidental deaths in this review were preventable, including deaths due to motor vehicle collisions and drowning. In deaths due to homicide, the perpetrator was often known to the victim, whether as an acquaintance or family member. Toxicology testing was often positive in decedents of the older age group, while only rarely positive in decedents of the younger age group. With a solid understanding of the circumstances, it may be possible to predict, and hopefully prevent, future cases of adolescent death. The authors present their findings in this 15-year retrospective study to better aid forensic pathologists, death investigators, law enforcement, and epidemiologists.     

Level of agreement between opinions of medical examiner investigators and forensic pathologist medical examiners regarding the manner of death

To evaluate the level of agreement between medical examiner investigators' opinion of the manner of death and what the manner of death was as certified by forensic pathologist medical examiners (MEs), we reviewed the case records stored in a database of all deaths reported to the office of the medical examiner in Fulton County, Georgia. Of 15,771 deaths reported to the office during a 10-year period, a difference exists in 1908 cases. In 900 natural deaths, the investigators recorded 135 accident, 10 homicide, 10 suicide, and 745 undetermined manners of death. In 755 accidental deaths, the investigators recorded 16 natural, 8 homicide, 13 suicide, and 718 undetermined manners of death. In 107 homicides, the investigators recorded 12 natural, 8 accident, 0 suicide, and 87 undetermined manners of death. In 70 suicides, the investigators recorded 9 natural, 9 accident, 3 homicide, and 49 undetermined manners of death. In 61 deaths classified as undetermined, the investigators recorded 25 natural, 13 accident, 17 homicide, and 6 suicide manners of death. In 15 deaths, the discrepancy exists due to an apparent error in the database information. This study confirms a high concordance between investigator and ME opinion regarding manner of death but also documents the need for case review and autopsies by forensic pathologists to confirm the investigators' opinion of the manner of death, determine the manner of death when the investigator selects undetermined, and on occasion, refute the investigators' opinion regarding the manner of death.     

Drug prevalence in drowning deaths in Cuyahoga County, Ohio: a ten-year retrospective study

Previous studies have shown that up to 50% of adult drownings are related to the consumption of alcohol. Little information is available in the literature regarding the possible contribution of ethanol and other drugs to drownings.All records of deaths occurring in Cuyahoga County, Ohio, from 1994-2003, in which drowning was listed as the cause of death, were reviewed. Toxicology analysis was performed on cases where specimens were submitted. Review of the 187 cases showed that the majority (78%) of drowning deaths were ruled as accidents, 26 (14%) as suicide, 5 (3%) as homicide, and 11 (6%) as undetermined.Among the accidental deaths (n=141), 97 (69%) were negative for all drugs, including ethanol, and 30 cases (21%) were positive for ethanol only. Illicit drugs were detected in 4 of the cases (3%). In the suicides (n=26), 16 (62%) were negative for all drugs, including ethanol, and 7 cases (27%) were positive for ethanol only (mean blood alcohol concentration [BAC] 0.03 g/dL). Illicit drugs were detected in 3 of the cases (12%). Two of the 5 homicide cases (40%) were positive for ethanol. There were no cases in which the victim tested positive for illicit drugs.Of the 11 cases ruled as undetermined, 64% (n=7) were negative for all drugs, including ethanol. The remainder of the cases tested positive for ethanol only. There were no cases in which illicit drugs were detected. This study demonstrates that the majority of drowning deaths in Cuyahoga County, Ohio, were not drug related. Deaths in which drugs were detected were typically accidental deaths, with ethanol the most common drug detected.     

Ten years of "body packers" in New York City: 50 deaths

We reviewed all 50 body packer deaths in New York City from 1990 to 2001. The majority (37/50) of deaths were caused by acute intoxications due to open or leaking drug packets in the gastrointestinal tract. The number of packets recovered ranged from 1 to 111 (average 46). The weight of the combined packets ranged from 9.4 to 1,200 g (average of 377). The age ranged from 19 to 57 years (mean 37.1). The decedents were: 82% male, 66% Hispanic, 24% Black, and 10% White. The manners of death were 47 accidents, 1 homicide, 1 natural, and 1 undetermined. The causes of death included 42 acute intoxications, 5 intestinal obstructions/bowel perforations, 1 gunshot wound, 1 intracerebral hemorrhage due to hypertensive disease, and 1 undetermined. Of the 50 decedents, 42 were transporting opiates, 4 cocaine, and 4 both opiates and cocaine. There were 9 deaths from 1990-1995 and 41 from 1996-2001. Of the 41 deaths between 1996 and 2001, only 6 involved cocaine. In New York City there has been an increase in body packer deaths from the early 1990s to the late 1990s. Along with this increase is a marked predominance of opiate body packer deaths with few cocaine deaths.     

Subway Train‐Related Fatalities in New York City: Accident versus Suicide*

Abstract: We examined the characteristics of subway train‐related fatalities in New York City between Jan. 1, 2003 and May 31, 2007 in order to determine which factors are useful in differentiating accident from suicide. Subway train‐related deaths with homicide and undetermined manners also are included. During this period, there were 211 subway train‐related fatalities. The manners of death were: suicide (n = 111), accident (n = 76), undetermined (n = 20), and homicide (n = 4). The causes of death were blunt trauma (n = 206) and electrocution (n = 5). Torso transection and extremity amputation were more frequent in suicides. Antidepressant medications were more frequently detected in suicides, whereas cocaine and ethanol were more frequent in accidents. However, autopsy findings should be weighed in the context of the entire evaluation along with other circumstantial and investigative findings. In unwitnessed deaths where additional information is unavailable or discrepant, the most appropriate manner of death usually is undetermined.     

Forensic dental identifications in the greater Houston area.

In order to confirm the identity of the deceased, 1.7% of the deaths (162 cases) evaluated at the Harris County Medical Examiner's Office during the time period of this study required a forensic dental evaluation. Data were collected and analyzed. The manner of death was ranked in order as follows: 30% homicide; 20% accident of various types other than motor vehicle accidents; 18% motor vehicle accidents; 16% remain undetermined; 9% natural causes; and 7% suicide. The cause of death was: 24% asphyxia, smoke inhalation, or thermal burn injuries; 23% blunt-force trauma; 18% miscellaneous causes of death; 15% undetermined; 13% gun shot wounds; and 7% asphyxia. The condition of the remains were: 38% charred or incinerated; 31% decomposing; 18% skeletal remains; 6% "fresh" or recently deceased; 4% fragmented; and 3% severely beaten or mangled with displacement of the maxillomandibular region, complicating the dental identification procedure. The gender was: 62% male; 34% female; and 4% undetermined. The race was: 55% Caucasian; 19% Hispanic; 14% black; 1% Asian; and 11% undetermined. The age was: 2% from 0 to 10 years of age; 9% from 11 to 20; 21% from 21 to 30; 18% from 31 to 40; 13% from 41 to 50; 8% from 51 to 60; 5% from 61 to 70; 4% from 71 to 80; 1% from 81 to 90; and 19% undetermined. Further evaluation of these and future dental identification cases will provide valuable data to help prepare the forensic dentist for the wide variety of cases that must be evaluated in the course of their careers.     

Fatal descent from height in New York City

All deaths due to descent from height that underwent autopsy at the Manhattan Office of Chief Medical Examiner of New York City over a two year period (1997-1999) were reviewed. The scene and autopsy findings, psychiatric history, and toxicology results were examined. There were 120 deaths: 77 suicides, 36 accidents, 5 undetermined, and 2 homicides. Psychiatric illness was reported in 86% of suicides. The toxicological detection of psychiatric medications supports the high percentage of psychiatric disease in the suicide group. In the accidental group, the detection of ethanol and illicit drugs was higher (36%) than expected from the case investigation and similar to the suicide group (29%). Accidental falls by women made up fewer than 3% of all manners. Due to the variation in the extent of injuries, it is unwise to attempt to conclude how high a person descended based on the autopsy findings. Descents into water commonly have minimal findings on external examination with marked internal injuries. The methods of investigation and criteria for death certification using the study results are discussed.     

Postmortem wound dehiscence. A report of three cases

Three cases of healing incised wounds that dehisced following death are reported. All three deaths were apparent drownings during summer months. The incised wounds had occurred from 1 week to 6 months prior to death. The length of post-mortem immersion ranged from 2 days to 3 weeks, and all three decedents exhibited significant decompositional changes. Proper recognition of this postmortem artifact eliminates undue suspicions and contributes to proper identification.     

Evaluation of Non‐Natural Deaths among Veterans: New Mexico Medical Examiner‐Investigated Deaths, 2002–2011

While it is recognized that veterans have increased rates of depression, post‐traumatic stress disorder (PTSD), suicide, and substance use disorders, rates of homicide and unintentional injury deaths in veterans have been minimally investigated. We evaluated all non‐natural deaths in New Mexico veterans between 2002 and 2011 in comparison with non‐natural deaths among non‐veterans. We reviewed all decedents in New Mexico with a history of military service and investigated by the medical examiner, excluding natural deaths and deaths due to fall from standing height. The most common manner of death was unintentional injury (62%), most of these deaths due to motor vehicle accidents (29%) followed by unintentional overdose (26%). Suicide rates among veterans were consistently higher than the general population. The most common mechanism of suicide in men was gunshot wound (72%), and intentional overdose in women (49%). Services are needed for veterans that are tailored to all ages and both sexes.     

Firearm Deaths by Law Enforcement

Abstract:  The use of deadly force during law enforcement is a matter that compels public scrutiny. There were 42 gunshot deaths caused by police over a 4-year period in New York City. The decedents' average age was 31 years and ranged from 17 to 64 years. There were 41 males and one female; and 26 Black, nine Hispanic, and seven White decedents. Ethanol and/or drugs of abuse were detected in 78% (31/40) of the decedents. The vast majority of shootings occurred with the police responding to a crime and 90% of the decedents were armed (26 handguns, six knives, one axe, one metal pipe, and one toy gun). Vehicles were used as weapons in two incidents. A total of 177 bullets struck the 42 decedents. Fourteen decedents sustained single gunshot wounds (GSWs), and the remainder had multiple GSWs ranging from 2 to 21. In the majority of the cases in this study, the number of GSWs of the body was three or fewer. Thirteen decedents had at least one GSW of the back or buttocks, accounting for 25 of the total 177 wounds, and four of the 13 had GSWs of only the back. With the exception of the upper extremities, GSWs of all locations were more likely to penetrate than perforate. Although these deaths may be high profile, the certification is typically straightforward and the cause (i.e., GSW) and manner of death (homicide) are readily apparent. Although police shootings in which the decedent was unarmed and/or sustained numerous GSWs are widely reported by the lay press, these types of shootings were not typical in our study.     

Sharp injury fatalities in New York City

We reviewed the case records of all fatalities due to sharp injuries in New York City in 1999. The epidemiological profile, circumstances, toxicology results, location, and injuries were examined. There were 120 deaths: 101 homicides, 17 suicides, and 2 accidents. The causes of death included: 112 due to stab(s) with or without incised wounds and 8 pure incised wound fatalities of which 5 were suicides. The detection of ethanol and/or illicit drugs was 61% in the homicide and 12% in the suicide groups. "Defense wounds" were reported in 49% of the homicides and "hesitation" wounds were found in 65% of the suicides. There were no self-inflicted sharp injuries of the face. Deaths due to a single stab wound occurred in 34% (34/101) of the homicides and 24% (4/17) of the suicides. Of these 38 deaths, 58% were of the anterior thorax (chest) and 71% injured the heart and/or great vessels. The remaining deaths with single stab wounds involved the femoral artery, abdominal organs, or head. There were no sharp injury suicides by Hispanics, Asians, or anyone under the age of 18 years. Over half of the suicides at home occurred in the bathroom and 78% of these occurred in the bathtub. Suicide notes were found in 24% of suicides, and an additional 24% verbally expressed a plan to commit suicide.     

Methadone-related deaths in Hennepin County,Minnesota: 1992-2002

Methadone maintenance therapy (MMT) is the only currently established medical therapy for heroin addiction. However, MMT still remains controversial. In Hennepin County, Minnesota, methadone is one of the top ten drugs reported in medical examiner investigated deaths and one of the most commonly diverted pharmaceuticals. This report reviews the role of methadone in medical examiner deaths over a 10-year period, 1992-2002. We compare cause and manner of death (accidental, natural, suicide) and methadone blood concentrations for decedents who were members of MMT programs with illicit users and those prescribed methadone for chronic pain. Findings reveal that 65% of decedents with measurable blood methadone concentrations were not participating in MMT programs. A total of 96 cases were identified, with the majority white (90.5%) and male (76.8%). MMTP program members were the minority (34.7%) of the methadone positive deaths and 39% were illicit users. Fifteen percent were chronic pain patients with almost half of this group dying from overdose. Methadone concentrations of drug caused/related deaths (0.18-3.99 mg/L) overlapped with those of deaths not attributable to methadone (0.18-3.03 mg/L) with no definable lethal level. Interpretation of methadone blood concentrations must be done in the context of the clinical history for determining cause of death, and may be confounded by postmortem redistribution.     

Trends in Officer‐involved Firearm Deaths in Oklahoma from 2000 to 2015

The purpose of this study was to collect data and disseminate trends in officer‐involved firearm deaths in Oklahoma from 2000 to 2015. The Oklahoma Office of the Chief Medical Examiner (OCME) database was searched for civilian decedents with gunshot wounds inflicted by law enforcement officers and officer decedents with gunshot wounds inflicted by civilians. Five decedents were law enforcement officers, while 274 decedents were civilians. The number of civilian decedents throughout the study followed a quadratic trend. Civilian decedents were most commonly males (95%) between the ages of 20 and 39 (64%), had one or two gunshot wounds (46%), and had an increasing number of gunshot wounds over time. Postmortem toxicology testing most commonly detected ethanol, methamphetamine, cocaine, and PCP. Efforts toward increased tracking by various agencies and more scientific studies like this are needed to facilitate future analysis of trends in officer‐involved firearm deaths.     

Psychosocial Complications of Crohn's Disease and Cause of Death

Patients who suffer from Crohn's disease are prone not only to the complications of a relapsing, unpredictable disease, but also to feelings of stigmatization; depression; and increased risk of suicidal ideation, suicide, or drug and alcohol abuse. Cases performed at the Jackson County Medical Examiner's Office from 2008 to 2010 were reviewed. Autopsy findings, investigator reports, toxicology results, medical records, and interviews with survivors were analyzed. Twelve cases of Crohn's disease were recovered. In 10 of these cases, inflammatory bowel disease was not the cause of death. Instead, psychosocial consequences of the disease had significant implications in the deaths. The mean age of decedents was 45 years, with a female predominance. In eight cases, the decedents lived alone. Five patients had issues of acute or chronic drug or alcohol use. Five patients committed suicide. These cases underscore the role of psychosocial factors that can contribute significantly to the cause of death in patients with Crohn's disease.     

The happy land homicides: 87 deaths due to smoke inhalation

We reviewed all 87 deaths from the Happy Land Social Club fire. All deaths were due to smoke inhalation. The carboxyhemoglobin (COHb) concentrations ranged from 37 to 93% with a mean of 76.5%. The vast majority (97%) of the decedents had a COHb concentration over 50%. Cyanide blood concentrations ranged from 0 to 5.5 mg/L with a mean of 2.2 mg/L. Nine decedents had no cyanide detected, and seven had cyanide concentrations of less than 1 mg/L. Fewer than one third of the decedents had thermal injuries, and most were partial thickness burns involving less than 20% body surface area. Ethanol was detected in 72% of decedents with a range of 0.01 to 0.29 g% and a mean blood concentration of 0.11 g%. Cocaine or cannabinoid use was identified in 9% of the decedents. All decedents were visually identified, and all had soot in the airway extending to the major bronchi. Carboxyhemoglobin concentrations corresponded well with deaths from smoke inhalation. Cyanide concentrations did not correspond with the extent of smoke inhalation, and the role of cyanide in contributing to these deaths is doubtful. Hydrogen chloride inhalation, as evidenced by comparison of the pH of tracheal mucosa to controls, was not a factor.     

Suicide by asphyxiation due to helium inhalation

Suicide by asphyxiation using helium is the most widely-promoted method of "self-deliverance" by right-to-die advocates. However, little is known about persons committing such suicides or the circumstances and manner in which they are completed. Prior reports of suicides by asphyxiation involving helium were reviewed and deaths determined by the North Carolina Office of the Chief Medical Examiner to be helium-associated asphyxial suicides occurring between January 1, 2000 and December 31, 2008 were included in a new case series examined in this article. The 10 asphyxial suicides involving helium identified in North Carolina tended to occur almost exclusively in non-Hispanic, white men who were relatively young (M age = 41.1 T 11.6). In 6 of 10 cases, decedents suffered from significant psychiatric dysfunction; in 3 of these 6 cases, psychiatric disorders were present comorbidly with substance abuse. In none of these cases were decedents suffering from terminal illness. Most persons committing suicide with helium were free of terminal illness but suffered from psychiatric and/or substance use disorders.