Over a three-month period in early 2017, the Hennepin County Medical Examiner's Office investigated nine apparent opioid toxicity deaths that occurred in three separate urban, suburban, and rural counties in our jurisdiction. All decedents were known substance abusers and had reportedly recently used heroin; most were found with drug paraphernalia. Complete autopsies variably showed classic stigmata of opioid overdose with no significant injury or natural disease to explain death. Initial toxicology screens failed to identify heroin or other narcotic substances. Several cases were presumptively positive for fentanyl by immunoassay, yet failed to confirm positive for fentanyl. Following American Board of Forensic Toxicology reporting standards, these cases were reported as negative for fentanyl by the laboratory. Due to the discrepant scene and toxicology findings suggestive of an opioid toxicity death, further discussion between the medical examiners and toxicologists prompted additional testing at a referral laboratory. This resulted in quantifiable blood carfentanil in all cases (mean 0.26 ng/mL, range 0.12-0.64 ng/mL). Cointoxicants included ethanol (n=2), methamphetamine (n=3), benzodiazepines (n=3), and cocaine (n=1). No case had definitive evidence of acute heroin intoxication, but two cases had low concentrations of morphine present (0.03 and 0.06 ng/mL), and two others had 6-monoacetyl morphine in the urine without morphine in the blood, suggesting recent use. All deaths were certified as accidental acute or mixed carfentanil toxicity. These cases present additional information about carfentanil-related deaths and highlight the importance of collaboration between forensic pathologists and toxicologists.
Hypothermia deaths are frequently accidental and associated with impairment by alcohol, injuries, mental illness, or natural disease. Hypothermia as a method of suicide is unusual, with only nine case reports in the scientific literature. In the early months of 2014, during one of the coldest winters on record, the Hennepin County Medical Examiner's office investigated and certified two unrelated cases of suicide by hypothermia; we describe the salient features of these cases. A retrospective review of all cases investigated by our office from January 1991-April 2014 identified 146 cases in which “hypothermia” or “environmental cold exposure” was listed as a cause of death, contributing condition, or mechanism of injury. Death investigation narratives and autopsy reports were reviewed to confirm hypothermia and evaluate for the presence or absence of characteristic hypothermia findings. In these cases the manner of death was certified as follows: 116 accident (79.4%), 15 undetermined (10.3%), 8 suicide (5.5%), 6 natural (4.1%), and 1 homicide (0.7%). Further examination of the eight suicide cases revealed that half were female and half were male, and most were younger individuals with only one decedent above 50 years of age. Four of these deaths were associated with drug toxicities, five were associated with additional self-inflicted injuries (blunt force, sharp force, and/or gunshot wounds), and none of them exhibited paradoxical undressing. It is important for medicolegal death investigation professionals to recognize that, while rare, hypothermia deaths may represent intentional injury, and suicide as a manner of death should be considered in all cases.
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