Department of Forensic Medicine

et al. A crosssectional survey using electronic distribution of a questionnaire to subscribers of educational material written by clinicians, for clinicians, to evaluate whether practice change resulted from reading the Clinical Communiqué. BMJ Open 2017;7:e014064.

et al. A crosssectional survey using electronic distribution of a questionnaire to subscribers of educational material written by clinicians, for clinicians, to evaluate whether practice change resulted from reading the Clinical Communiqué. BMJ Open 2017;7:e014064.

et al. A crosssectional survey using electronic distribution of a questionnaire to subscribers of educational material written by clinicians, for clinicians, to evaluate whether practice change resulted from reading the Clinical Communiqué. BMJ Open 2017;7:e014064.

Introduction: "King hits" are when a single blow to the head causes a victim to fall to the ground unconscious, either from the punch itself or the impact between the head and the ground. This can result in fatal skull fractures and subdural hematomas. This study aimed to establish the prevalence of king hit deaths in Australia and determine the involvement of drugs in these violent fatalities. Methods: The National Coronial Information System was used to retrieve all cases involving a king hit within Australia between 2000 and 2012.

In the present study, the effects of amphetamine-class drugs were examined in cases reported to the Victorian coroner from 2001 to 2005 to determine if death can occur from the use of amphetamine-class drugs alone. A total of 169 cases were reviewed where a forensic autopsy detected amphetamine(s) in the blood. Pathology, toxicology, and police reports were analyzed in all cases to ascertain the involvement of amphetamine-class drugs in these deaths. In Victoria, methamphetamine (MA) is the principal abused amphetamine-class followed by methylenedioxymethamphetamine (MDMA). There were six cases in which a cerebral hemorrhage caused death and three cases in which serotonin syndrome was established as being caused by the interaction of MDMA and moclobemide. There were 19 cases in which long-term use of amphetamines was associated with heart disease. There were three cases where amphetamine-class drugs alone were regarded as the cause of death, of which two cases exhibited high levels of MDMA and lesser amounts of MA and ⁄ or amphetamine. There were no cases in which significant natural disease was absent and death was regarded as caused by the use of MA. There was no correlation between blood concentration of drug and outcome.

Inappropriate combinations of pharmaceutical drugs are often detected in deaths reported to a coroner. However, the involvement of drug combinations in the cause of death can be overlooked in cases when significant natural disease or external injury is also present. This study examined pathology reports and coroner's findings between January 2002 and December 2008. Cases that included exposure to a selection of serotonergic drugs were examined to determine the role of different death investigators in drug-associated deaths in Victoria, Australia. Of the 326 cases identified, the involvement of drugs in the death was discussed to some degree in 66% of cases. Recommendations by the coroner pertaining to death prevention were made in 12 cases (4%). In 16 cases (5%) the drugs were not mentioned in the findings, including at least 11 cases of probable major adverse drug interactions. Death investigations serve an important public health and safety role, however, the potential involvement of drugs in many cases is not always recognized.

Objectives: To examine trends in codeine-related mortality rates in Australia, and the clinical and toxicological characteristics of codeine-related deaths. Design and setting: Analysis of prospectively collected data from the National Coronial Information System on deaths where codeine toxicity was determined to be an underlying or contributory cause of death. The study period was 2000e2013. Main outcome measures: Population-adjusted numbers (per million persons) of (1) codeine-related deaths, classified by intent (accidental or intentional); and (2) heroin-and Schedule 8 opioid-related deaths (as a comparator). Results: The overall rate of codeine-related deaths increased from 3.5 per million in 2000 to 8.7 per million in 2009. Deaths attributed to accidental overdoses were more common (48.8%) than intentional deaths (34.7%), and their proportion increased during the study period. High rates of prior comorbid mental health (53.6%), substance use (36.1%) and chronic pain (35.8%) problems were recorded for these deaths. For every two Schedule 8 opioid-related deaths in 2009, there was one codeine-related death. Most codeine-related deaths (83.7%) were the result of multiple drug toxicity. Conclusions: Codeine-related deaths (with and without other drug toxicity) are increasing as the consumption of codeine-based products increases. Educational messages are needed to better inform the public about the potential harms of chronic codeine use, especially in the context of polypharmacy.

The prevalence of opioid use in therapeutic and recreational settings has steadily increased throughout the western world. The addition of fentanyl into heroin products can produce potentially dangerous consequences, even to opioid tolerant individuals who may be unaware of such additions. Following an observed spike of heroin-fentanyl related deaths in Melbourne, Australia, a study was undertaken to determine the prevalence of these cases. All reportable deaths occurring in Victoria during 2015 and submitted to the toxicology laboratory were analysed using LC-MS-MS to confirm the combination of the heroin marker 6-acetylmorphine and/or morphine, and fentanyl. Over 4,000 coronial cases in 2015 underwent toxicological analysis for these drugs, there were nine cases identified that involved fentanyl-laced heroin. There was no specific mention of fentanyl use in any of these cases. All occurred within 2 months and in two distinct locations. The first four deaths occurred within 3 days of each other, in neighboring suburbs. The ages ranged from 25 to 57 years with an average of 40 and median of 37 years, and consisted of eight males and one female. The average and median femoral blood concentration of fentanyl was 18 and 20 ng/mL (range: <1-45 ng/mL), and morphine 140 and 80 ng/mL (range: 20-400 ng/mL), respectively. All nine cases had 6-acetylmorphine detectable in blood. Urine analysis was also performed where available. A syringe, powder and spoon found at the scene of one case were also analysed and found to be positive for both heroin and fentanyl, which supported the likelihood of fentanyl-laced heroin. This is the first reported case series of fatalities involving heroin and fentanyl outside of North America in published literature. These findings may help inform public health and prevention strategies serving to decrease the potential for such fatalities in the future.

To describe the frequency and nature of deaths from resident-to-resident aggression (RRA) in nursing homes in Australia. National population-based retrospective cohort study. Accredited nursing homes in Australia. Residents whose deaths resulted from RRA and were reported to the coroner between July 1, 2000, and December 31, 2013. Cases were identified using the National Coronial Information System, and data on individual, interpersonal, organizational, and societal factors were collected through review of the paper-based coroners&#39; files. This research identified 28 deaths from RRA over a 14-year study period (0.004 per 100,000 bed days). Most exhibitors of aggression were male (n = 24, 85.7%), and risk of death from RRA was twice as high for male as for female nursing home residents (relative risk (RR) = 2.13, 95% confidence interval (CI) = 0.93-4.80, P = .05). Almost 90% of residents involved in RRA had a diagnosis of dementia, and three-quarters had a history of behavioral pr...

Suicide among nursing home residents is a growing public health concern, currently lacking in empirical research. This study aims to describe the frequency and nature of suicide among nursing home residents in Australia. This research comprised a national population-based retrospective analysis of suicide deaths among nursing home residents in Australia reported to the Coroner between July 2000 and December 2013. Cases were identified using the National Coronial Information System, and data collected from paper-based coroners&#39; records on individual, incident, and organizational factors, as well as details of the medico-legal death investigation. Data analysis comprised univariate and bivariate descriptive statistical techniques; ecological analysis of incidence rates using population denominators; and comparison of age and sex of suicide cases to deaths from other causes using logistic regression. The study identified 141 suicides among nursing home residents, occurring at a rat...

The aim of this study was to determine the relationship between alcohol co-ingestion in an index deliberate self-poisoning (DSP) episode with repeated DSP and subsequent suicide. A retrospective cohort study was conducted involving 5,669 consecutive index presentations to a toxicology service following DSP between January 1, 1996, and October 31, 2010. Records were probabilistically matched to National Coronial Information System data to identify subsequent suicide. Index DSPs were categorized on co-ingestion of alcohol, and primary outcomes analyzed were repetition of any DSP, rates of repeated DSP, time to first repeat DSP, and subsequent suicide. Co-ingestion of alcohol occurred in 35.9% of index admissions. There was no difference between those who co-ingested alcohol (ALC+) and those who did not co-ingest alcohol (ALC-) in terms of proportion of repeat DSP, number of DSP events, or time to first repeat DSP event. Forty-one (1.0%) cases were probabilistically matched to a suicid...

Background. &#x27;Under-reporting&#x27; of deaths to the coroner has significant implications for the identification and investigation of preventable deaths. In extreme cases, it may even be a symptom of the system failures that allowed cases such as Harold Shipman, Australia&#x27;s King Edward Memorial ...

To describe the nature and extent of external-cause deaths of residents of nursing homes in Victoria, Australia. A retrospective cohort study of all decedents using routinely collected data contained within the National Coronial Information System. Accredited nursing homes in Victoria. Nursing home residents who had died from external causes and whose deaths were reported to the Coroners Court between July 1, 2000, and December 31, 2012. Basic descriptive analysis was conducted to measure frequencies and proportion of exposures within each outcome group, and rates were calculated using population data. One thousand two hundred ninety-six external cause deaths of nursing home residents were identified. Deaths were due to falls (n = 1,155, 89.1%), choking (n = 89, 6.9%), suicide (n = 17, 1.3%), complications of clinical care (n = 8, 0.6%) and resident-on-resident assault (n = 7, 0.5%). Deaths occurred more frequently in women (n = 814, 62.8%), in keeping with the sex distribution in n...

Background: resident-to-resident aggression (RRA) is an understudied form of elder abuse in nursing homes. Objective: the purpose of this systematic review was to examine the published research on the frequency, nature, contributing factors and outcomes of RRA in nursing homes. Methods: in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement, this review examined all original, peer-reviewed research published in English, French, German, Italian or Spanish between 1st January 1949 and 31st December 2013 describing incidents of RRA in nursing homes. The following information was extracted for analysis: study and population characteristics; main findings (including prevalence, predisposing factors, triggers, nature of incidents, outcomes and interventions). Results: eighteen studies were identified, 12 quantitative and 6 qualitative. The frequency of RRA ranged from 1 to 122 incidents, with insufficient information across the studies to calculate prevalence. RRA commonly occurred between exhibitors with higher levels of cognitive awareness and physical functionality and a history of aggressive behaviours, and female targets who were cognitively impaired with a history of behavioural issues including wandering. RRA most commonly took place in the afternoon in communal settings, was often triggered by communication issues and invasion of space, or was unprovoked. Limited information exists on organisational factors contributing to RRA and the outcomes for targets of aggression. Conclusions: we must continue to grow our knowledge base on the nature and circumstances of RRA to prevent harm to an increasing vulnerable population of nursing home residents and ensure a safe working environment for staff.

Background: Medico-legal death investigations are a recognised data source for public health endeavours and its accessibility has increased following the development of electronic data systems. Despite time and cost savings, the strengths and limitations of this method and impact on research findings remain untested. This study examines this issue using the National Coronial Information System (NCIS). Methods: PubMed, ProQuest and Informit were searched to identify publications where the NCIS was used as a data source for research published during the period 2000-2014. A descriptive analysis was performed to describe the frequency and characteristics of the publications identified. A content analysis was performed to identify the nature and impact of strengths and limitations of the NCIS as reported by researchers. Results: Of the 106 publications included, 30 reported strengths and limitations, 37 reported limitations only, seven reported strengths only and 32 reported neither. The impact of the reported strengths of the NCIS was described in 14 publications, whilst 46 publications discussed the impacts of limitations. The NCIS was reported to be a reliable source of quality, detailed information with comprehensive coverage of deaths of interest, making it a powerful injury surveillance tool. Despite these strengths, researchers reported that open cases and missing information created the potential for selection and reporting biases and may preclude the identification and control of confounders. Conclusions: To ensure research results are valid and inform health policy, it is essential to consider and seek to overcome the limitations of data sources that may have an impact on results.

There is a paucity of research examining the utility of forensic toxicology in the investigation of premature external cause deaths of residents in nursing homes. The aim of this study is to describe the frequency and characteristics of toxicological analysis conducted in external cause (injury-related) deaths amongst nursing home residents in Victoria, Australia. This study was a retrospective cohort study examining external cause deaths among nursing home residents during the period July 1, 2000 to December 31, 2012 in Victoria, Australia, using the National Coronial Information System (NCIS). The variables examined comprised: sex, age group, year-of-death, cause and manner of death. One-third of deaths among nursing home residents in Victoria resulted from external causes (n = 1296, 33.3%) of which just over one-quarter (361, 27.9%) underwent toxicological analysis as part of the medical death investigation. The use of toxicological analysis varied by cause of death with a relati...