Coroner Service Research Articles

Chronic disease diagnoses and health service use among people who died of illicit drug toxicity in British Columbia, Canada.

Illicit drug toxicity (i.e., overdose) is the leading cause of death in British Columbia (BC) for people aged 10-59. Stimulants are increasingly detected among drug toxicity deaths. As stimulant useand detection in deaths rises, it is important to understand how people who die of stimulant toxicity differ from people who die of opioid toxicity. BC Coroners Service records were retrieved for all people who died of unintentional illicit drug toxicity (accidental or undetermined) between January 1, 2015, and December 31, 2019, whose coroner investigation had concluded and who had an opioid and/or stimulant detected in post-mortem toxicology and identified by the coroner as relevant to the death (N = 3788). BC Chronic Disease Registry definitions were used to identify people with chronic disease. Multinomial regression models were used to examine the relationship between chronic disease diagnoses and drug toxicity death type. Of the 3788 deaths, 11.1% (N = 422) had stimulants but not opioids deemed relevant to the cause of death (stimulant group), 26.8% (N = 1014) had opioids but not stimulants deemed relevant (opioid group), and 62.1% (N = 2352) had both opioids and stimulants deemed relevant (opioid/stimulant group). People with ischemic heart disease (1.80 (1.14-2.85)) and people with heart failure (2.29 (1.25-4.20)) had approximately twice the odds of being in the stimulant group as compared to the opioid group. Findings suggest that people with heart disease who use illicit stimulants face an elevated risk of drug toxicity death. Future research should explore this association and should identify opportunities for targeted interventions to reduce drug toxicity deaths among people with medical comorbidities.

Estimating the impacts of nonoptimal temperatures on mortality: A study in British Columbia, Canada, 2001-2021.

Studies show that more than 5.1 million deaths annually are attributed to nonoptimal temperatures, including extreme cold and extreme heat. However, those studies mostly report average estimates across large geographical areas. The health risks attributed to nonoptimal temperatures in British Columbia (BC) are reported incompletely or limit the study area to urban centers. In this study, we aim to estimate the attributable deaths linked to nonoptimal temperatures in all five regional health authorities (RHAs) of BC from 2001 to 2021. We applied the widely used distributed lag nonlinear modeling approach to estimate temperature-mortality association in the RHAs of BC, using daily all-cause deaths and 1 × 1 km gridded daily mean temperature. We evaluated the model by comparing the model-estimated attributable number of deaths during the 2021 heat dome to the number of heat-related deaths confirmed by the British Columbia Coroners Service. Overall, between 2001 and 2021, we estimate that 7.17% (95% empirical confidence interval = 3.15, 10.32) of deaths in BC were attributed to nonoptimal temperatures, the majority of which are attributed to cold. On average, the mortality rates attributable to moderate cold, moderate heat, extreme cold, and extreme heat were 47.04 (95% confidence interval [CI] = 45.83, 48.26), 0.94 (95% CI = 0.81, 1.08), 2.88 (95% CI = 2.05, 3.71), and 3.10 (95% CI = 1.79, 4.4) per 100,000 population per year, respectively. Our results show significant spatial variability in deaths attributable to nonoptimal temperatures across BC. We find that the effect of extreme temperatures is significantly less compared to milder nonoptimal temperatures between 2001 and 2021. However, the increased contribution of extreme heat cannot be ruled out in the near future.

Concurrent use of opioids and stimulants and risk of fatal overdose: A cohort study

BackgroundStimulant use has been rising among people with opioid use disorder in recent years in North America, alongside a parallel rise in illicit drug toxicity (overdose) deaths. This study aimed to examine the association between stimulant use and overdose mortality.MethodsData from a universal health insurance client roster were used to identify a 20% random general population sample (aged ≥12) in British Columbia, Canada (N = 1,089,682). Provincial health records were used to identify people who used opioids and/or stimulants. Fatal overdose observed during follow-up (January 1 2015-December 31 2018) was retrieved from Vital Statistics Death Registry and BC Coroners Service Data. Potential confounders including age, sex, health region, comorbidities and prescribed medications were retrieved from the provincial client roster and health records.ResultsWe identified 7460 people who used stimulants and or opioids. During follow-up there were 272 fatal overdose events. People who used both opioids and stimulants had more than twice the hazard of fatal overdose (HR: 2.02, 95% CI: 1.47-2.78, p < 0.001) compared to people who used opioids only. The hazard of death increased over time among people who used both opioids and stimulants.ConclusionsThere is an urgent need to prioritize the service needs of people who use stimulants to reduce overdose mortality in British Columbia. Findings have relevance more broadly in other North American settings, where similar trends in opioid and stimulant polysubstance use have been observed.

Of River Yala Dead Bodies: Recrudescing National Coroners Service Act 2017: A Case Study

Of River Yala Dead Bodies: Recrudescing National Coroners Service Act 2017: A Case Study

Overdose deaths and the COVID-19 pandemic in British Columbia, Canada.

British Columbia (BC) declared an overdose public health emergency in 2016. Since then, BC has consistently reported the highest overdose death rates of any province in Canada. In the context of the COVID-19 pandemic, overdose deaths in BC reached a record high in 2020. This analysis reports on changes in the profile of people who have died of overdose since BC's declaration of COVID-19 as a public health emergency on 17 March 2020. Using BC Coroners Service data, Chi-square tests and multivariable logistic regression were conducted to compare demographic, geographic and post-mortem toxicology data between people who died of overdose before (17 March-31 December 2019) and after (17 March-31 December 2020) BC's declaration of COVID-19 as a public health emergency. Overdose deaths observed since 17 March 2020 (n= 1516) more than doubled those observed in the same period in 2019 (n= 744). In the adjusted logistic regression model, odds of death in the post compared to pre-COVID-19 period was significantly higher among males compared to females, among all older age groups compared to people aged 30-39, and was lower in public buildings compared to private residences. Alongside a significant increase in overdose deaths since BC's declaration of COVID-19 as a public health emergency, the demographic profile of people who have died of overdose has changed. Ongoing overdose prevention efforts in BC must seek to reach people who remain most isolated, including older adults, who during dual public health emergencies are facing compounded risk of preventable mortality.

Comparing mortality from covid-19 to mortality due to overdose: A micromort analysis

ObjectiveTo compare the mortality risk due to covid-19 with death due to overdose in British Columbia, Canada. The opioid epidemic was declared a public health emergency in 2016. MethodsMortality risk was calculated in micromorts with covid-19 data for January–October 2020, derived from the BC center for Disease Control, and illicit drug toxicity deaths for January 2010–September 2020, derived from the BC Coroners Service. Age-stratified covid-19 incidence and deaths per 100,000 population and age-stratified illicit drug toxicity death rates per 100,000 population were calculated. A micromort is a unit of risk equivalent to a one-in-a-million chance of death. ResultsDuring the covid-19 pandemic, illicit drug toxicity deaths reached 1.0 micromorts per day, representing an increase of 0.5 micromorts per day relative to 2019 rates. In comparison, covid-19 mortality risk was 0.05 micromorts per day among individuals from the general population living in British Columbia and 21.1 micromorts per day among those infected with covid-19. Covid-related mortality risk was significantly lower among individuals aged <60 years, relative to older adults, whereas drug toxicity-related mortality was highest for individuals aged 30–59 years. ConclusionsThe mortality associated with covid-19 is apparent and distributed unevenly across subpopulations. The mortality due to overdose has increased during covid-19 and exceeds mortality due to covid-19. Our results instantiate the triple threat caused by covid-19 (i.e., public health crisis, economic crisis and mental health crisis) and quantitatively highlight the externality of increased mortality due to deaths of despair in response to public health efforts to reduce covid-related mortality.

Fall-related deaths among older adults in British Columbia: cause and effect of policy change

BackgroundThe British Columbia Coroners Service implemented a policy in 2010 advising the reclassification of underlying causes of deaths due to falls from ‘natural’ to ‘accidental’. This study investigates whether observed...

Toxicology and prescribed medication histories among people experiencing fatal illicit drug overdose in British Columbia, Canada

<h3>BACKGROUND:</h3> Since 2015, illicit drug overdose has been one of British Columbia’s most pressing public health issues. Our objective was to assess prescription history in the context of postmortem toxicology among people who had a fatal illicit drug overdose in BC. <h3>METHODS:</h3> Toxicology results from drug overdose deaths involving 1 or more illicit drugs, as identified by the BC Coroners Service in 2015–2017, were linked to the prescription drug histories of individuals as recorded in BC’s PharmaNet database for a descriptive analysis. Substances identified in toxicology were considered prescribed if the individual had an active dispensation for a matching medication within 60 days before overdose. <h3>RESULTS:</h3> There were 2872 deaths from illicit drug toxicity during the study period; 1789 (62.3%) were closed cases with toxicology results available. In 85.5% of cases, 1 or more opioids were found to be relevant to death. Prescribed opioids in the absence of nonprescribed opioids were detected in only 2.0% of cases, and 6.7% had a combination of prescribed and nonprescribed opioids. Among those with 1 or more nonprescribed opioids, 78.5% had fentanyl or fentanyl analogues detected. Medications used in opioid agonist therapy (methadone and buprenorphine) were found to be relevant to death in 7.4% of cases, with methadone (130 cases) much more common than buprenorphine (&lt; 5 cases). Stimulants were detected in 70.6% of cases. <h3>INTERPRETATION:</h3> Our data show a high prevalence of nonprescribed fentanyl and stimulants, and a low prevalence of prescribed opioids detected on toxicology in people who died from illicit drug overdose. These results suggest that strategies to address the current overdose crisis in Canada must do much more than target deprescribing of opioids.

Seven ways to fate and all

This script is the outcome of a practice-led research project exploring the exponential growth in British Columbia of fentanyl-detected illicit drug overdose deaths. A September 2017 summary from The BC Coroners Service’s confirms a 143% increase in the number of deaths. In the canon of dramatic screenplays, few scripts explore the domain of drug addiction exclusively as a subject. In The Man with the Golden Arm (1955), Frank Sinatra plays Frankie Machine, a drug addict who becomes clean in prison and yearns to be a drummer. Yet, his heroin addiction is never specified. In Clean and Sober (1988) Michael Keaton is an alcoholic and cocaine addicted realtor who hides in a treatment center. However, in the recent, Emmy Award winning television series, Breaking Bad, Walter White’s sidekick, Jesse Pinkham, is clearly a heroin addict. My screenplay differs from the above dramas in that most characters are not confirmed addicts. In my dramatized script I portray characters from many walks of life: teenagers, parents, actors, politicians, and the homeless, and show how they struggle with the impact of illicit drug usage. It can happen to anyone. As a character states in Way Five, “It (meaning addiction) is a health issue.” Rather than a screed about illicit opioid use, my screenplay attempts to inform, open conversations and transform attitudes.

Illicit drug overdose deaths resulting from income assistance payments: Analysis of the ‘check effect’ using daily mortality data

BackgroundAlthough income assistance is an important source of support for low income individuals, there is evidence that adverse outcomes may increase when payments are disbursed on the same day for all recipients. The objective of this study was to assess the temporal patterns and causal relation between population-level illicit drug overdose deaths and income assistance payments using daily mortality data for British Columbia over a period of five years. MethodsRetrospective data on daily mortality due to illicit drug overdose, 2009–2013, were provided by the BC Coroners Service. These data were analyzed using regression models and time series tests for causality in relation to dates of income assistance payments. Results1343 deaths due to illicit drug overdose were reported in BC during 2009–2013; 394 occurred during cheque weeks (n=60) and 949 occurred during non-cheque weeks (n=202). Average weekly mortality due to illicit drug overdose was 40% higher during weeks of income assistance payments compared to weeks without payments (P<0.001). Consistent increases in mortality appeared the day after cheque disbursement and were significantly higher for two days, and marginally higher after 3 days, even when controlling for other temporal trends. Granger causality testing suggests the timing of cheque issue was causally linked to increased drug overdose mortality (P<0.001). ConclusionsOur findings clarify the temporal relation and causal impact of income assistance payments on illicit drug deaths. We estimate 77 avoidable deaths were attributable to the synchronized disbursement of income assistance cheques over the five year period. An important consideration is whether varying the timing of payments among recipients could reduce this excess mortality and the related demands on health and social services.

Bereaved relatives’ experiences in relation to post mortem: a qualitative exploration in North East Scotland

When a family is grieving the loss of a member the consideration of post mortem is an additional concern. This study set out to explore how relatives are supported to give authorisation and throughout the post mortem process. Thirteen relatives with varied experiences of a relative's death took part in interviews. Data analysis revealed the post mortem as part of the narrative of the death, with more significance for some than others. Important aspects for relatives were being able to say ‘goodbye’ properly, and engagement with staff in hospital and procurator fiscal (public prosecution) services in more substantive communicative relationships, rather than only receiving basic information. Relatives valued receiving results they could understand. There may be opportunities, particularly in coroner or procurator fiscal services, for development of roles in liaison between relatives and pathology services, and support for relatives.

A geospatial analysis of the relationship between neighbourhood socioeconomic status and adult severe injury in Greater Vancouver

BackgroundEvery year, injuries cost the Canadian healthcare system billions of dollars and result in thousands of emergency room visits, hospitalisations and deaths. The purpose of this study was to explore...

Building health care system capacity: training health care professionals in disaster preparedness health care coalitions.

This study aimed to learn from the experiences of well-established, disaster preparedness-focused health care coalition (HCC) leaders for the purpose of identifying opportunities for improved delivery of disaster-health principles to health professionals involved in HCCs. This report describes current HCC education and training needs, challenges, and promising practices. A semi-structured interview was conducted with a sample of leaders of nine preparedness-focused HCCs identified through a 3-stage purposive strategy. Transcripts were analyzed qualitatively. Training needs included: stakeholder engagement; economic sustainability; communication; coroner and mortuary services; chemical, biological, radiological, nuclear, and explosives (CBRNE); mass-casualty incidents; and exercise design. Of these identified training needs, stakeholder engagement, economic sustainability, and exercise design were relevant to leaders within HCCs, as opposed to general HCC membership. Challenges to education and training included a lack of time, little-to-no staff devoted to training, and difficulty getting coalition members to prioritize training. Promising practices to these challenges are also presented. The success of mature coalitions in improving situational awareness, promoting planning, and enabling staff- and resource-sharing suggest the strengths and opportunities that are inherent within these organizations. However, offering effective education and training opportunities is a challenge in the absence of ubiquitous support, incentives, or requirements among health care professions. Notably, an online resource repository would help reduce the burden on individual coalitions by eliminating the need to continually develop learning opportunities.

Attending coroner's court: a practical guide

It will happen to many of us during our medical careers. We will receive a summons to give evidence at a coroner's inquest, and the nerves will start to run riot.

The Sacramental Significance of the Coronation

The Queen remains in robust health but, inevitably, as she gets older there is speculation about the form and content of the next coronation service, whenever it may be needed.

Improper use of child restraint seats as a sleeping environment: Two cases of childhood death

A child restraint seat (CRS) is designed to keep infants safe inside motor vehicles while in motion. However, there have been a growing number of reports of injuries sustained as a result of CRS use outside the vehicle. These injuries commonly result from a fall from an elevated surface or an overturning of the CRS. The incidence of death from these events, however, is not well documented. The present report retrospectively analyzed the British Columbia Coroner Service Database to identify deaths involving CRS use outside the vehicle. Two such fatalities were identified. In both instances, infants had been placed in a CRS overnight and, in both cases, the CRS was found overturned, resulting in asphyxiation. The history and pathological findings of both cases are summarized.

Does direct transport to provincial burn centres improve outcomes? A spatial epidemiology of severe burn injury in British Columbia, 2001–2006

In Canada and the United States, research has shown that injured patients initially treated at smaller emergency departments before transfer to larger regional facilities are more likely to require longer stays in hospital or suffer greater mortality. It remains unknown whether transport status is an independent predictor of adverse health events among persons requiring care from provincial burn centres. We obtained case records from the British Columbia Trauma Registry for adult patients (age ≥ 18 yr) referred or transported directly to the Vancouver General Hospital and Royal Jubilee Hospital burn centres between Jan. 1, 2001, and Mar. 31, 2006. Prehospital and in-transit deaths and deaths in other facilities were identified using the provincial Coroner Service database. Place of injury was identified through data linkage with census records. We performed bivariate analysis for continuous and discrete variables. Relative risk (RR) of prehospital and in-hospital mortality and hospital stay by transport status were analyzed using a Poisson regression model. After controlling for patient and injury characteristics, indirect referral did not influence RR of in-facility death (RR 1.32, 95% confidence interval [CI] 0.54- 3.22) or hospital stay (RR 0.96, 95% CI 0.65-1.42). Rural populations experienced an increased risk of total mortality (RR 1.22, 95% CI 1.00-1.48). Transfer status is not a significant indicator of RR of death or hospital stay among patients who received care at primary care facilities before transport to regional burn centres. However, significant differences in prehospital mortality show that improvements in rural mortality can still be made.

Suicide by Oxygen Deprivation with Helium: A Preliminary Study of British Columbia Coroner Investigations

This article researches a relatively new suicide method advanced by right-to-die organizations: oxygen deprivation by breathing helium inside a plastic hood. The article begins with a review of the role of the coroner and the history of oxygen deprivation with helium; it then examines 20 Judgements of Inquiry (JOI) by British Columbia coroners into this form of suicide. The JOI were obtained through the Freedom of Information and Protection of Privacy Act and cover the period of 1999 to 2007. Findings raise concerns about the coding system used by coroners as well as adherence to internal documentation guidelines. The British Columbia Coroners Service (BCCS) has a public safety mandate to investigate all unnatural deaths and to make recommendations to prevent deaths in similar circumstances. It is a concern that BCCS has no recommendations to prevent suicides by oxygen deprivation with helium. More in-depth, systematic research is recommended to determine the prevalence of suicide by oxygen deprivation and to develop strategies to benefit public health and safety.

Are we homogenising risk factors for public health surveillance? Variability in severe injuries on First Nations reserves in British Columbia, 2001–5

BackgroundAboriginal Canadians are considered to be at increased risk of injury. The de facto standard for measuring injury risk factors among Aboriginal Canadians is to compare hospitalisation and mortality against...

A review of sudden unexpected death in the young in British Columbia

Since 2008, all pediatric deaths in British Columbia have been reported to the coroner. The cause of death in pediatric sudden unexpected death (SUD) remains undetermined in 10% to 30% of cases. Before 2008, there was no standardized approach for referring relatives of SUD victims for follow-up medical testing to determine whether they were affected by the same condition. In the current era, genetic testing for primary electrical diseases can be used in cases of undetermined SUD when existing diagnostic methods fail. To improve the clinical care of surviving relatives of SUD victims, the current practice of assessment of SUD in British Columbia was reviewed. The study also aimed to determine the prevalence of SUD and sudden cardiac death, types of postmortem investigations performed in SUD, and the use of genetic testing for primary electrical diseases in SUD from 2005 to 2007. Cases involving individuals zero to 35 years of age, with a death due to natural disease or an undetermined cause were compiled from the British Columbia Coroners Service database. Cases were determined to be either sudden death due to a previously diagnosed condition or SUD. In individuals zero to 35 years of age, the prevalence of SUD was 9.21 per 100,000 and the prevalence of sudden cardiac death was 5.26 per 100,000. There were 35 cases of SUD in which a cause of death was unidentified after autopsy (autopsy- negative SUD). Specimens were collected, and specialists were consulted in 86% of these cases in the pediatric population and 14% in the adult population. A suggestion was made to relatives to seek medical attention in 26% of the autopsy-negative SUDs, and molecular autopsy was discussed in 9% of cases but performed in none. Currently, SUD in British Columbia is not managed in a way that optimizes a timely diagnosis for surviving relatives. A standardized protocol for SUD is needed to ensure optimization of diagnosis, genetic testing and referral of surviving relatives.