Neuroleptic induced sudden death--a case report and critical review

Investigation of Deaths of Chronically Disabled Persons and Institutionalized Persons

The investigation of deaths involving chronically disabled and/or institutionalized persons represents an important challenge to the medicolegal death investigation community. For the purposes of this review, the chronically disabled and/or institutionalized are considered to include three non-mutually exclusive subcategories: the disabled elderly, the severely disabled, and psychiatric patients. Because deaths within certain of these populations tend to be common and expected, a very important goal when such deaths occur is the appropriate referral of cases to the medical examiner/coroner. Although each subcategory has distinct issues of importance regarding death investigation, there is also a reasonable amount of overlap between the three groups. This review provides an overview of the three subcategories, the reasons such persons may be at risk for premature, unexpected, or unnatural death, the many important issues of concern when investigating deaths within these vulnerable populations, and important preventative strategies within each group.

Sudden adult death

In the investigation of sudden death in adults, channelopathies, such as long QT syndrome, have risen to the fore in the minds of forensic pathologists in recent years. Examples of these disorders are touched upon in this review as an absence of abnormal findings at postmortem examination is characteristic and the importance of considering the diagnosis lies in the heritable nature of these conditions. Typically, a diagnosis of a possible channelopathy is evoked as an explanation for a 'negative autopsy' in a case of apparent sudden natural death. However, the one potential adverse effect of this approach is that subtle causes of sudden death may be overlooked. The intention of this article is to review and discuss potential causes of sudden adult death (mostly natural) that should be considered before resorting to a diagnosis of possible channelopathy. Nonetheless, it becomes apparent that many of the potential causes of sudden death can have a genetic basis. Thus, it becomes an important consideration that there may be a genetic basis to sudden death that extends beyond the negative autopsy.

Sudden death during restraint: a study to measure the effect of restraint positions on the rate of recovery from exercise

A small number of mental health patients have died suddenly following violent behaviour and restraint by staff. The safety of certain restraint positions has been questioned. This study evaluates two control and restraint (C & R) positions commonly used by health service staff. A repeated measures design was used to study rate of recovery from exercise in volunteer staff, measured by pulse oximetry, comparing the restraint positions with a seated (control) position. It was found that the recovery time for pulse rate of subjects restrained in a face-down position was significantly longer than for subjects restrained in a face-up position. No significant findings were made in terms of comparison between the control position and the restraint positions, and no significant changes in oxygen saturation were noted during restraint. It is concluded that restraint position may be a factor in death during restraint, but only where other factors contribute to the overall situation.

Sudden unexpected death in young adults including four cases of SADS: a 10-year review from the west of Ireland (1985-1994)

Sudden unexpected death in young adults of 18-35 years account for an important subset of deaths in our autopsy population. The case notes and autopsy reports in 44 subjects were analysed during the period 1985-94 at the Department of Histopathology, University College Hospital, Galway to establish the underlying cause of death. Subjects who were involved in road traffic accidents, cases of drowning, and patients with known congenital heart disease, chronic renal failure and malignancy were excluded. We found that a large proportion of sudden deaths in young adults were secondary to epilepsy and chemical/drug poisoning, accounting for 34 per cent and 31.8 per cent respectively. Sudden adult death syndrome (SADS) accounted for 9 per cent of the study population. Detailed case history, meticulous post-mortem examination and complete toxicological screening are recommended to arrive at the underlying cause of death.

Sudden unexplained death in a psychiatric patient--a case report: the role of phenothiazines and physical restraint

Psychotropic drug use has long been associated with sudden unexplained and unexpected death in psychiatric patients despite controversies surrounding the issue. Physical restraint following violent episodes in psychiatric in-patients is also associated with neurally mediated sudden cardiac death. A case where these two mechanisms have jointly resulted in sudden death is reported. The literature on the subject is reviewed and the measures which may be useful in reducing the incidence of such deaths are discussed. The need for accurate and detailed reporting of such cases is emphasized.

The obscure autopsy and neuroleptic malignant syndrome

The technique of immunocytochemistry was used to identify myoglobin in kidney, confirming a diagnosis of neuroleptic malignant syndrome following an otherwise obscure autopsy in a decomposed body. The features of neuroleptic malignant syndrome are reviewed with a differential diagnosis of myoglobin renal casts. The report emphasizes a thorough and detailed assessment of deaths which occur during treatment with neuroleptic drugs.