Using Forensic Toxicology to Enhance Medicolegal Death Investigations

The Milwaukee County Medical Examiner's Office performed an evidence-based review of natural deaths certified without autopsy or toxicology testing. Three hundred fifteen such cases from 2020 and 2021 were selected. This study reviewed the deaths to determine if the cause was drug-related instead due to natural disease.Blood samples were screened by liquid chromatography-quadrupole mass spectrometry with time-of-flight detector. The analytes detected were evaluated for contribution to the cause resulting in a change in manner from natural to accident or suicide. Confirmatory analysis was performed where appropriate, and results were reported to the forensic pathologist for evaluation. Where appropriate, the death certificate was amended.As a result of the screening and confirmatory work, 18 cases were identified where significant drugs were detected, and thus the cause and manner of death were amended. One case was amended from natural to suicide after a conversation with the family about the toxicology findings. The remaining cases were amended to a manner of accident. The scope of drugs responsible for the deaths included prescription and illicit.