What additional evidence is most useful for a complete mortality review?

Essential Evidence for Complete Mortality Review

For a comprehensive mortality review, standardized death-scene investigation protocols with comprehensive autopsy including full organ examination, complete radiographs, metabolic testing, and toxicology screening are essential, along with complete medical records review and registry-based mortality ascertainment. 1

Core Components of Mortality Review

Death Scene Investigation

• Implement standardized death-scene investigation protocols as per CDC guidelines, with trained medical examiners, coroners, death-scene investigators, first responders, and law enforcement conducting comprehensive investigations 1
• Document all environmental factors, circumstances surrounding death, and collect physical evidence systematically 1
• Photograph the scene and body position before any movement occurs 1

Comprehensive Autopsy Requirements

• Perform full external and internal examination of all major organs and tissues, including the brain 1
• Obtain complete radiographs of the entire body 1
• Conduct metabolic testing to identify underlying metabolic disorders 1
• Perform comprehensive toxicology screening on multiple specimens 1

Specimen Collection for Toxicology

• Collect blood from two distinct peripheral sites (preferably left and right femoral veins) to avoid postmortem redistribution artifacts 2
• Obtain urine (if available), vitreous humor from both eyes separately, representative stomach contents, and liver tissue (10-20g from right lobe) 2
• Add preservative (sodium fluoride 0.5-2% w/v) to blood and urine samples 2
• Consider hair and nail collection if chronic exposure is suspected 2
• Leave 10-20% headspace in tubes containing liquids if freezing is anticipated 2

Medical Records Review

• Obtain complete antemortem medical records, including all hospital records if death occurred after hospitalization 2
• Review surgical records to identify therapeutic drug administration that might otherwise be misinterpreted as abuse 3
• Document complete medication history, including timing of last doses 4
• Obtain occupational and environmental exposure history 2

Mortality Ascertainment Method

• Use registry-based or primary care-based mortality assessment rather than relying solely on hospital records, as this approach is associated with 19% mortality reduction in intervention studies and ensures complete case capture 1
• Implement National Death Index linkage for complete mortality follow-up in longitudinal studies 5

Critical Interpretation Factors

Toxicology Interpretation

• Consider postmortem redistribution, which can significantly alter drug concentrations depending on collection site and time elapsed since death 4, 6
• Measure metabolites to confirm reliability of parent drug measurements 4
• Compare results from multiple specimen types (blood, urine, vitreous humor) to validate findings 4, 2
• Account for postmortem changes including drug instability and production/loss of substances like alcohol 4, 6

Contextual Information Required

• Document complete circumstances of death including medical history, drug use history, and time-related factors 6
• Avoid listing only terminal events (respiratory failure, cardiac arrest) as cause of death; identify underlying illness 7
• Consider therapeutic drug administration in clinical settings before concluding illicit use 3

Child Death Review Process

• Establish multidisciplinary child death review teams with involvement of pediatricians and other primary care providers 1
• Allocate resources for maintaining training and conducting comprehensive investigations 1
• Implement standardized protocols across jurisdictions 1

Common Pitfalls to Avoid

• Never rely on single-site blood collection for toxicology, as central vessel blood may show falsely elevated concentrations due to postmortem redistribution 2
• Do not interpret drug presence without reviewing complete medical records, as therapeutic administration can mimic abuse patterns 3
• Avoid attributing death to mechanism (cardiac arrest) rather than underlying cause 7
• Do not skip vitreous humor collection, as it provides stable alcohol measurements when blood results are unreliable due to trauma 4