Death Investigation Research Articles

Administracyjnoprawne aspekty stwierdzenia zgonu

The subject of the article is a detailed analysis of the administrative and legal aspects of ascertainment causes of death. The first part of the article describes the Polish law regarding ascertainment death. Then, the author defines problems of interpretation and application of the law, as well as the author presents legislation project of new funeral law. The third subsection of the article relates to comparative law – selected aspects of the death investigation system, in particular the position of a coroner in England, Wales, the state of New York.

Contextual information in medicolegal death investigation decision-making: Manner of death determination for cases of a single gunshot wound

To explore the role of contextual information in determining manner of death, four cases involving single gunshot wounds were presented to participants (n = 252) involved in medicolegal death investigation. The participants received identical autopsy information but different contextual information. The data demonstrated that participants tended to rely on contextual information more than autopsy information: In the suicide context, participants across the four cases reached 153 final decisions of suicide (and 25 of homicide), whereas in the homicide context, participants reached only 10 final decisions of suicide (and 181 of homicide) --all while examining identical autopsy information. The impact of the contextual information was so powerful that many participants changed initial autopsy-based conclusions to align with the contextual information. Given the significant role and impact that contextual information has on expert decision making, one must consider what, how, and when contextual information should be used.

A Rapid Method for Postmortem Vitreous Chemistry-Deadside Analysis.

Vitreous fluid is commonly collected for toxicological analysis during forensic postmortem investigations. Vitreous fluid is also often analyzed for potassium, sodium, chloride and glucose for estimation of time since death, and for the evaluation of electrolyte imbalances and hyperglycemia, respectively. Obtaining such results in the early phase of a death investigation is desirable both in regard to assisting the police and in the decision-making prior to the autopsy. We analyzed vitreous fluid with blood gas instruments to evaluate/examine the possible impact of different sampling and pre-analytical treatment. We found that samples from the right and left eye, the center of the eye as well as whole vitreous samples gave similar results. We also found imprecision to be very low and that centrifugation and dilution were not necessary when analyzing vitreous samples with blood gas instruments. Similar results were obtained when analyzing the same samples with a regular multi-analysis instrument, but we found that such instruments could require dilution of samples with high viscosity, and that such dilution might impact measurement accuracy. In conclusion, using a blood gas instrument, the analysis of postmortem vitreous fluid for electrolytes and glucose without sample pretreatment produces rapid and reliable results.

Using death scene and toxicology evidence to define involvement of heroin, pharmaceutical morphine, illicitly manufactured fentanyl and pharmaceutical fentanyl in opioid overdose deaths, 38 states and the District of Columbia, January 2018-December 2019.

Tracking specific drugs contributing to drug overdose deaths is limited when relying on death certificate (DC) data alone. This study aimed to determine whether integrating DC data with medical examiner/coroner reports, including postmortem toxicology and death investigation findings, would enhance identification of (1) heroin and pharmaceutical morphine involvement in overdose deaths and (2) fentanyl source (illicitly manufactured versus pharmaceutical). Retrospective analysis of heroin, pharmaceutical morphine, illicitly manufactured fentanyl (IMF) and pharmaceutical fentanyl involvement in fatal overdoses. DC and toxicology data were compared with enhanced definitions integrating overdose scene, witness and toxicology evidence. United States: 38 states and the District of Columbia, participating in Centers for Disease Control and Prevention (CDC)-funded opioid overdose death surveillance. Opioid overdose decedents from funded jurisdictions; deaths during 1 January 2018-31 December 2019. Using medical examiner/coroner report data, deaths with 6-acetylmorphine and/or morphine detected by postmortem toxicology were defined as confirmed, probable or suspected heroin deaths, or probable pharmaceutical morphine deaths. Fentanyl was defined as probable or suspected IMF or probable pharmaceutical fentanyl. The enhanced definition defined 18 393 deaths as confirmed, probable, or suspected heroin deaths (including 2678 with morphine listed as cause of death on the DC) and 404 as probable pharmaceutical morphine deaths. Among deaths with fentanyl detected, 89.3% were defined as probable or suspected IMF and 1.0% as probable pharmaceutical fentanyl. Fentanyl source could not be determined for 9.7% of deaths. Integrating drug overdose scene, witness and toxicology findings can improve identification of specific drugs contributing to overdose deaths and enhance overdose intervention targeting.

Understanding the role of uncertainty and anxiety in police decision‐making during the investigation of sudden unexpected deaths in children

AbstractExisting policing policy offers a rational approach to decision‐making with minimal reference to human judgement within child death investigations. This study adopted a mixed methodology to capture decisional processes of 26 serving detective inspectors and detective sergeants whilst responding to an immersive scenario which simulated the first hours of a Sudden and Unexpected Death in Children (SUDC) investigation. Participants were presented with four decision points, during which they were asked to choose from decision options while reflecting upon personal and situational factors influencing that decision. Thematic analysis of responses found that investigators disclosed ‘anxiety’ and ‘uncertainty’ throughout their decision‐making during the scenario. In addition, there was no evidence of investigators utilising the models formally advocated within policing literature to make their decisions and assessments. As a result, it is suggested that further improvements are made regarding investigative decision‐making models within operational policing where ‘anxiety’ and ‘uncertainty’ is heightened.

Features of postmortem interval evaluation for the crime investigation

The work of police investigators includes investigation of violent deaths, when there is scarce information on peculiarities of death. The examination of corpse is essential in most of violent death cases; thus, there is a need to correctly evaluate signs on the corpse as soon as they could help investigators obtain important information about a murder. There could be various questions to be answered by forensic medical examiners; one of which is determination of time since death. The study is aimed to present guidelines on choosing the evaluation method for postmortem changes based on forensic medical data, in accordance with condition of the body, features of surroundings and other factors that have to be noted at the place of corpse’s finding. Guidelines are composed in accordance with current legal procedures on forensic medical examinations.

Retrospective study of non-natural manners of death in Ontario: Effects of the COVID-19 pandemic and related public health measures

BackgroundThe effects of the COVID-19 pandemic on non-natural manners of death in Ontario is not known. Understanding the indirect consequences of the pandemic and related public health measures (i.e. lockdown) fills a vital need to inform best practice in public health and guide policy decisions.MethodsThe Office of the Chief Coroner and the Ontario Forensic Pathology Service (OCC-OFPS) investigate sudden and unexpected deaths in the province of Ontario. The number of homicides, suicides, and accidental deaths (non-natural deaths=77,655) were extracted from the centralized Coroner's Information System database (total deaths=197,966), across four provincially defined stages of lockdown related to the COVID-19 pandemic (March 17 to December 31, 2020), and crude rates (per 100,000 people) were compared to the previous eleven years.FindingsThere was no major change to the rate of homicides during 2020 compared to 2009-2019 (RR 1⋅1, 95% CI 0⋅95-1⋅2; p=0⋅19; estimated annual effect=21 more deaths in 2020). The rate of suicides also did not show an overall major change in 2020 (RR 1⋅02, 95% CI 0⋅96-1⋅1; p=0⋅50; estimated annual effect=27 more deaths in 2020). However, during the first stage of lockdown (Stage 0), there was a decrease in the rate of suicides compared to all combinations of recent years from 2013 onwards (RRs 0⋅82-0⋅86, combined 95% CI 0⋅69-0⋅99; max p=0⋅039; estimated effect of 30 less deaths in Stage 0). There was an excess of over 1,500 accidental drug-related deaths that occurred during 2020 (RR 2⋅5, 95% CI 2⋅4-2⋅7; p<0⋅001). This finding held up to ‘interrupted time series’ robustness testing, indicating that 2020 had substantially more drug-related deaths, even when accounting for the linear increasing trend over time. Although motor vehicle collision associated fatalities appeared to decrease slightly in 2020 (RR 0⋅89, 95% CI 0⋅81-0⋅96; p=0⋅0039; estimated annual effect of 78 less deaths), we could not conclude any lockdown-associated effect, particularly when compared to 2019 (RR 0⋅26, 95% CI 0⋅75-1⋅1; p=0⋅26).InterpretationIn Ontario, the short-term effects of the COVID-19 pandemic did not greatly increase homicide or suicide rates, nor decrease motor vehicle collision fatality rates; however, the longer-term impact of the pandemic remains to be elucidated and ongoing vigilance is warranted in the event that other trends emerge. Accidental drug-related fatalities substantially increased during all stages of the lockdown, marking an urgent need for consideration in policy. These results highlight the vital role of death investigation systems in providing high quality and timely data to inform public health recommendations.FundingNone.

Adsorption of Therapeutic and Recreational Drugs During Prolonged Storage of Plasma Samples in Gel Separator Tubes.

Hospital samples collected in gel separator tubes are often submitted to forensic toxicology laboratories for analysis in impaired driving and death investigations. Drug adsorption to the gel separator material may lead to underestimation of the drug concentration present at the time of sample collection, potentially affecting the interpretation of analytical results. Using liquid chromatography--tandem mass spectrometry (LC--MS-MS), decreases in plasma concentration of 53 drugs and metabolites relevant to forensic toxicology casework were investigated in samples stored in BD Vacutainer® PSTTM tubes for up to 3 months. After storage for only 1 day, approximately 50% of the drugs and metabolites had significantly lower concentrations in plasma separation tubes (PSTs) compared to non-gel tubes (up to 27% lower). After storage for 3 months, approximately 75% of the drugs and metabolites had significantly lower concentrations in PSTs compared to non-gel tubes (up to 69% lower). Fentanyl, carfentanil, ketamine, diphenhydramine and several antidepressants were among the drugs most susceptible to adsorption. Central nervous system stimulants (e.g., methamphetamine and amphetamine) as well as naturally-occurring and semi-synthetic opioids (e.g., morphine, hydromorphone and oxycodone) were among the drugs least susceptible to adsorption and displayed only minimal relative decreases in concentration (if any) over the 3-month sample storage period. The potential for decreases in drug concentration due to adsorption of drugs to the gel material should be considered for toxicological interpretation based on the analysis of a sample collected in a gel separator tube.

Abstract 10914: Refining Genotype-Phenotype Correlations for Post-Mortem Genetic Testing of Sudden Cardiac Death: From the POST SCD Study

Introduction: The POST SCD (POstmortem Systematic InvesTigation of Sudden Cardiac Death) Study is the only prospective unbiased sudden cardiac death (SCD) cohort to use comprehensive postmortem investigation to refine the SCD phenotype to true cardiac and arrhythmic causes. Most postmortem genetic testing focuses on genotypes while tolerating a SCD phenotype that is presumed cardiac. Hypothesis: We hypothesize that a comprehensive postmortem evaluation following presumed SCD will refine genotype-phenotype associations and interpretation of postmortem genetic testing. Methods: The POST SCD study prospectively identified all deaths attributed to out-of-hospital cardiac arrest between 18-90 years of age in San Francisco County between February 2011-March 2014 (20,440 deaths reviewed). Medical record review identified 525 presumed SCDs that met World Health Organization criteria. Comprehensive autopsy, toxicology, and histology ruled out non-arrhythmic causes (overdose, hemorrhage, PE) to arrive at 293 sudden arrhythmic deaths (SADs). In the first 30 SADs with high suspicion for heritable cause, a comprehensive 300-gene cardiac/arrhythmia panel was performed, then whole exome testing in cases with negative or non-contributory panel. Results: By pathologic criteria, the 30 autopsy-defined SADs (21 males [70%], median age 53 years) for genetic testing included dilated cardiomyopathy (37%), hypertrophic cardiomyopathy (HCM; 10%), hypertrophy without pathologic features of HCM (33%), primary electrical disease (10%), arrhythmogenic cardiomyopathy (3%), mitral valve prolapse (3%), or non-compaction (3%). In 3 SADs, we identified 4 pathogenic/likely pathogenic (P/LP) variants in APOB , MYBPC3 , GAA , and TTN , but 3 of 4 ( APOB, GAA , TTN ) were non-contributory to SCD. There were 61 variants of uncertain significance in 24 patients (80%). Further exome testing in 7 SADs identified no compelling variants. Conclusions: Postmortem genetic testing identified P/LP variants in 10% of autopsy-proven SADs with high suspicion for heritable cause, but detailed postmortem phenotyping excluded 75% as non-contributory to SCD. These results highlight the importance of comprehensive autopsy evaluation to refine genotype-phenotype correlations.

Extracorporeal membrane oxygenation in the forensic setting: A series of 19 forensic cases.

Extracorporeal membrane oxygenation (ECMO) employs vascular cannulation and a gas exchange circuit to provide support to patients with severely compromised cardiopulmonary function. ECMO is often the last intervention taken before death and thus presents a unique challenge to medical examiners. This study describes the characteristics of decedents on ECMO at the time of death, including clinical indications, types of circuit configurations, causes and manners of death, gross findings at autopsy, and therapeutic complications. Files of a regional medical examiner office within an academic medical center were searched for the period between 2013 and 2019. Nineteen cases were identified with a median age of 36years. The circumstances surrounding the initial presentation included: sudden death, trauma, substance abuse, homicide, therapeutic complication, work-related injury, drowning, and hypothermia. The underlying causes of death included injury-related, as well as respiratory and cardiac-related natural diseases. The time spent on ECMO varied from less than 1h to 10months. Complications encountered due to ECMO included cannulation site bleeding, pneumohemopericardium, retroperitoneal hematoma, limb ischemia, clotting, and cannula dislodgement. The patient population likely to receive ECMO has significant overlap with death circumstances likely to be reported to the medical examiner. As ECMO therapy has become increasingly available, it is of importance for medical examiners and death investigators to be familiar with the procedure as well as its limitations. Familiarity with ECMO and its sequelae allows for the proper documentation of postmortem findings and fosters an informed determination of the cause and manner of death.

Investigation of Children's Deaths Reported in Media Between 2005 and 2019 in Turkey

Investigation of Children's Deaths Reported in Media Between 2005 and 2019 in Turkey

Children’s death survey using death certificates in the Chiba prefecture

In recent years, Child Death Review (CDR) has attracted attention in Japan. It is necessary to consider not only hospital deaths but also out-of-hospital deaths. However, recommending preventive measures may be difficult because statistics on Japanese child mortality are limited. We examined cause of death (COD) and its application in preventive medicine based on death certificates (DCs) in the Chiba Prefecture. Death documents (DDs) and death slips (DSs) were created for individuals aged under 20 years who died between January 2012 and December 2016. They were based on DCs submitted to the Chiba Prefecture. We examined the trend of COD, occurrence of extrinsic mortality, and characteristics of doctors and compared CODs mentioned in DCs with autopsy results. For 1149 cases, the descriptions of DSs and DDs matched. Half of the extrinsic and undetermined deaths, which were examined by police doctors, occurred out-of-hospital. The autopsy rate was 13.5%. The COD mentioned in DCs did not match the autopsy results for 26 out of 69 autopsies performed at our institute. Approximately 70% of sudden infant death syndromes were diagnosed without autopsy. Low autopsy rate, incorrect writings, and errors during the death diagnosis cannot be ignored while conducting CDR. As more than half of the preventable deaths occurred out-of-hospital and there is no system to collect detailed information on them, the Japanese CDR system may not be reliable. It is necessary to improve the death investigation system by promoting autopsies for children and constructing a comprehensive database.

Untangling a cat’s cradle: Diphacinone, acetaminophen, trauma, and multiple deaths in a Kentucky cat colony

• Free-roaming cats are subject to many causes of illness, injury, and death. • Cats are among the most common targets of malicious poisoning. • Diagnosis requires consideration of all findings/evidence. • Analytical results alone are insufficient to diagnose poisoning. This manuscript describes an animal cruelty investigation in which several cats from a feral colony were suspected of having been poisoned. Three of the cats were submitted for complete postmortem examination by a qualified veterinary pathologist, and appropriate toxicologic analyses were selected and interpreted by a qualified veterinary toxicologist. Diagnosis in poisoning cases requires communication and collaboration between the pathologists and the toxicologist. A truly definitive diagnosis is not always possible in poisoning cases, particularly in a forensic investigation – a court of law requires a higher standard to establish a cause of death than do routine diagnostic cases. This case series illustrates the importance of a thorough diagnostic workup in forensic animal death investigations.

Assessment of Mortality Pattern Based on Autopsy in Victims of Road Traffic Accident

Background: The Trauma and road accident is considered as major cause mortality in the young adults’ populations around the world. The understanding the importance of forensic investigation of un-natural deaths, accidental injuries and suicidal cases is required by medical staff and patients’ family members. Objective: To asses of mortality pattern based on autopsy in victims of road traffic accident Study Design: Retrospective study Place and Duration of the Study: Medicolegal Section of Liaquat University Hospital Hyderabad, Pakistan from 1st January 2018 to 31st December 2019. Methodology: Six hundred and twenty nine autopsies were included. Deaths due to road traffic accident were included. Results: There were 472 males and 157 females between 31 to 50 years. Two hundred and forty nine patients were admitted in ICU. Two hundred and fourteen patients had affected head region followed by face 104 injuries. While 74 had affected neck, 67 affected thorax, 63 affected abdominal region, 52 affected spine and 55 had affected lower extremities.173 were died due to damage of central nervous system. The damages were due to car accident was 62, motorbike 73, rickshaw 22 and other reasons 14. One hundred and forty patients were died due to fracture of skull. Conclusion: The mortalities rates are under reported in majority of accidental cases due to lacking of autopsies procedures. Keywords: Autopsy, Assessment, Mortality pattern, Road traffic accident

Medicolegal death investigator workplace safety hazards: A scoping review of the literature.

In the United States, medicolegal death investigation practices and policies pertaining to sudden unexpected deaths are mandated by state government. Practices vary across states, which contributes to inconsistency in job prerequisites and training. In preparation for a study focused on occupational safety and health of medicolegal death investigators in their on-scene and follow-up activities, a scoping review was conducted to document known occupational safety risks and health-related conditions associated with death investigation. Searches used Boolean and subject heading operators both broad and narrow in scope, and search terms included scene responder, hazard, investigator, forensic pathology, injury, and safety. Twenty-five articles met inclusion criteria, which included seventeen survey-mixed method designs, two systematic reviews, five quasi-experimental designs, and one case study. Twelve articles addressed mental health and eleven focused on risks associated with infectious disease. One article addressed the risk of chemical exposure from cyanide among autopsy personnel (including forensic pathologists) and nine included a wide range of employees within the setting of medical examiner or coroner offices. One article, addressing burnout, included employees in a forensic science laboratory setting as well as medicolegal death investigators and two articles included forensic pathologists and medicolegal death investigators. Only one article addressed medicolegal death investigators specifically. Articles addressing occupational and environmental hazards of medicolegal death investigators associated with musculoskeletal, respiratory, cardiovascular, radiological, nuclear, electrical, or explosive threats were not identified. There is little published about safety risks inherent in conducting death investigations. Research is needed to adequately inform health promotion and injury prevention strategies.

Unearthing the evidence: post-mortem interrogation of cardiac implantable electronic devices

Abstract Background The diagnostic yield of post-mortem interrogation of cardiac implantable electronic devices (CIEDs) including pacemakers, defibrillators and implantable loop recorders has not been well described. Methods We reviewed all post-mortem CIED interrogations performed by our statewide Institute of Forensic Medicine between 2005–2020 for investigation of sudden or unexplained death. Results 260 patients (68.8% male, median age 72.8 years [IQR 62.7–82.2]) underwent post-mortem CIED interrogation (202 pacemakers, 56 defibrillators and 2 loop recorders). CIEDs were implanted for a median of 2.0 [IQR 0.75–5] years, with 19 devices requiring replacement (and 5 end of life). Post-mortem interrogation was successful in 256 (98.5%) cases. Potential CIED malfunction was identified in 21 (8.1%) cases: untreated ventricular arrhythmias (n=13), lead failures (n=3) and battery depletion (n=5). CIED interrogation directly informed cause of death in 130 (50.0%) cases, with fatal ventricular arrhythmias identified in 121 patients (46.5%). In retrospect, 72 (27.7%) patients had abnormalities recorded by their device in the 30 days preceding death: non-sustained ventricular tachycardia (n=26), rapid atrial fibrillation (n=17), longevity concerns (n=22), intrathoracic impedance alarms (n=3), lead issues (n=3) or therapy delivered (n=1). In 6 cases where the patient was found deceased after a prolonged time, CIED interrogation accurately determined time of death. In one case, CIED interrogation was the primary method of patient identification. Conclusion Post-mortem CIED interrogation frequently contributes important information regarding critical device malfunction, pre-mortem abnormalities, cause and time of death or patient identity. Device interrogation should be considered for select patients with CIEDs undergoing autopsy. Funding Acknowledgement Type of funding sources: None.

Efficacy of folic acid therapy for the association between high serum vitamin B12 level with all cause mortality among hypertensive population: the CSPPT randomized clinical trial post-hoc analysis

Abstract Background While higher vitamin B12 level was found to be co-related with mortality in various population, the effectiveness of folic acid therapy for this association remained unknown. Purpose 1: Explore the association between high B12 level and all cause mortality in hypertensive population. 2: To test the primary hypothesis that therapy with enalapril and folic acid is more effective in reducing all cause mortality than enalapril alone among targeted population. Methods Current study used post hoc analysis to examin data from the china stroke primary prevention trial (CSPPT), a randomized, double-blind, multi-center clinical trial. After excluded those lack of vitamin B12 data and with extreme B12 value, 20,204 participants (mean age 60 [SD. 8.54]; 59.16% male gender; total mean serum vitamin B12 level 410.51 [SD. 124.85] pg/ml) were included in present study.10,093 participants were treated with enalpril alone and 10,111 patients took the combine use of enalapril and folic acid. The primary outcome was all cause mortality, which collected based on hospital issued death certificate and investigation during follow up period. Results Over the medium follow-up time of 4.5 years, 308 death occurred in enalapril group and 295 death happened in enalapril-folic acid group. Differences were observed regarding sex, center, smoking &amp; drinking status at baseline. In enalapril group, high vitamin B12 level presented positive linear association with all cause mortality and was found to be significantly differences (P=0.018). Whereas no association between high vitamin B12 level and all cause mortality were observed in enalapril and folic acid group. (P=0.448). KM curves and tertile analysis of vitamin B12 level also showed same finding. Sensitivity analysis were processed to ensure the accuracy of the study result. Conclusion The present study not only explored that higher vitamin B12 level will increase all cause mortality in hypertensive population, but also found that high vitamin B12 level loses its co-relationship with all cause mortality after folic acid therapy, which potentially reflected the benefits of long-term, low-dose folic acid supplementation. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Key R&amp;D Projects, Jiangxi National Key Research and Development Program Smoothing curveKM curve

Survey on postmortem screening and management of COVID-19 related deaths.

SummaryThe COVID-19 pandemic is associated with a high case fatality rate in some countries even thought the majority of cases are asymptomatic. Scientific studies on this novel virus is limited and there is uncertainty regarding the best practices for death investigations both in terms of detection of the disease as well as autopsy safety. An online survey was conducted to identify how different institutions responded to the screening and management of dead bodies during the early phase of the pandemic from January to May. A questionnaire was developed using Google Forms and data was collected from 14 different forensic and pathological institutions in 9 countries. None of the institutions had performed any screening prior to March. Four institutions stated that screening was done routinely. In total, 322 cases had been screened using RT-PCR, out of which 40 positive cases were detected among four institutions. The commonest types of samples obtained were nasopharyngeal and oropharyngeal swabs which also had the highest rates of positivity followed by tracheal swab. Blood, swabs from cut surfaces of lung and lung tissue also gave positive results in some cases. Majority of the positive cases were > 65 years with a history suggestive of respiratory infection and were clinically suspected to have COVID-19 before death. Except for one institution which performed limited dissections, standard autopsies were conducted on all positive cases. Disposal of bodies involved the use of sealed body bags and labelling as COVID positive. Funeral rites were restricted and none of the institutions advocated cremation. There were no reports of disease transmission to those who handled COVID positive bodies.

Flualprazolam distribution in postmortem samples.

The constant emergence of novel psychoactive substances is troubling to both public health officials and legislators. Additionally, sufficient data collection for each new compound can take months up to years. Flualprazolam, a triazolobenzodiazepine, quickly garnered attention as a sedative drug that likely expresses adverse reactions similarly to alprazolam. This study focuses on the distribution of flualprazolam in multiple common postmortem matrices. Central blood, vitreous humor, liver homogenate, brain homogenate, gastric contents, and urine samples from death investigation cases were quantitated when available. Samples were screened with liquid chromatography quadrupole time-of-flight with limit of detection set at 4ng/ml and quantitated on liquid chromatography tandem mass spectrometry, with concentration range from 4 to 256ng/ml. From August 2018 to September 2020, 24 central blood samples were quantitated for flualprazolam. Central bloods of 22 cases had concentrations above the limit of quantitation. The average flualprazolam central blood concentration was 16.3ng/ml with a median of 9.95ng/ml (4.24-48.0). Additional analyses for unconjugated flualprazolam were performed on at a total of 15 urine samples ( =14.4, 4.07-36.1ng/ml), 23 brain homogenates ( =23.2, 3.99-69.3ng/g), 23liver homogenates ( =50.7, 13.6-156ng/g), five vitreous humor samples ( =7.70, 4.03-12ng/ml), and 12gastric contents samples ( =0.36, 0.02-2.51mg). The cause of death for 13 of the 24 cases listed flualprazolam as a contributing factor of death.

Etizolam Blood Concentrations in 191 Forensic Cases in Ontario, Canada (2019-2020).

Although not used clinically in North America, etizolam has been identified in forensic samples as an illicit 'designer' benzodiazepine. As a central nervous system depressant, analysis for etizolam has probative value in both death investigations and forensic cases where incapacitation or human psychomotor performance is relevant. This report examines toxicological findings and demographic data in a series of authentic forensic cases analyzed between November 2019 and December 2020 in which etizolam was quantified by liquid chromatography-tandem mass spectrometry analysis. Blood concentrations were determined in 191 individuals aged 1-75 years. In living individuals (i.e., impaired driving and sexual assaults), etizolam concentrations ranged from <5 to 767 ng/mL which overlapped with the range of <5 to 260 ng/mL reported in death investigations. In all but one case, other drugs were detected in combination with etizolam. Fentanyl was the most common co-occurring drug and was present in 164 cases (86%). Additional case details are provided for cases of forensic interest: two deaths involving children <3years of age, two deaths involving body packing and an individual arrested for drug-impaired driving with, to our knowledge, the highest reported etizolam concentration to date.