REVIEW ARTICLE Systematic Review of Postmortem ……
SYSTEMATIC REVIEW OF POSTMORTEM EXAMINATION IN
TOXICOLOGICAL FATALITIES
BY
ELPHAS SHIKOKOTI SIAYI (BSC. MLS)
Department of Medical Laboratory Sciences,, Faculty of Public Health, Masinde Muliro University of
science and technology,Kenya.
ABSTRACT
Postmortem examination in intoxicated deaths is required to establish the cause and manner of death. It
relies mainly on the identification of drugs or their known metabolites. This review provides a
comprehensive account of toxicological fatalities involving investigative data, autopsy findings, analytical
methods, and toxicological results. Postmortem diagnosis of fatal intoxications is complicated. Autopsy
findings indicative of an intoxication-related death are scarce and mostly unspecific. Instead, the diagnosis
is more dependent on the circumstances surrounding death, and on the toxicological results. The collection
of specimens is the first and most important step in the toxicological examination as the proper biological
specimens can maximize the chance of obtaining meaningful analytical findings. Since deterioration of
specimens increases with postmortem time interval, biological specimens should be collected as soon as
possible after death. Additionally, the collection of specimens after the autopsy is rarely possible. To
correctly evaluate the toxicological results, the forensic investigator needs to separate between the lethal and
non-lethal concentrations. While a wealth of scientific data exists concerning concentrations and effects in
experimental animals and in living human subjects, these data cannot simply be translated into postmortem
concentrations. Due to various changes occurring in the early phase after death, the postmortem
concentration of a substance often does not mirror the concentration antemortem.
In conclusion, it is important to correlate the clinical and autopsy findings with the toxicology results to
appropriately evaluate toxicological deaths. Postmortem reference values are needed, and more studies
should be hired for the establishment of postmortem reference concentrations.
Keywords: Autopsy, Intoxication deaths, Sampling, Reference values.
E. mail: suggest poisoning. A toxicological
investigation should also be performed in
1. Introduction he legal basis for a cases of homicides, traffic accidents,
T medicolegal cause of death occupational accidents, suspicions of
investigation differs between malpractice, and where the immediate cause
countries. The investigation is usually of death is unknown following an autopsy.
started by the police, who seek the expertise The deaths of known drug and alcohol abusers
of the authority in charge of forensic are often associated with accidental or suicidal
medicine, often resulting in an autopsy overdoses. A toxicological investigation is
performed by a forensic pathologist or a desirable in all cases involving children and
medical examiner (Hanzlick, 2007). The young adults, regardless of their apparent cause
medicolegal autopsy rate varies greatly of death (Di Candia et al., 2022).
between countries, from a few percent to over Postmortem toxicological investigations
20% of all deaths. have traditionally been used to resolve
Likewise, the rate of postmortem individual cases. However, postmortem
toxicological investigations depends on a toxicology can serve society in a broader sense
multitude of factors. These include by contributing to death statistics and scientific
differences between types of postmortem studies, as in studies on drugs related to motor
cases and between requests from individual vehicle crashes (Mørland et al., 2011).
forensic pathologists and medical examiners A precise post-mortem examination is a
(Ojanperä and Vuori, 2014). fundamental part of the evaluation of
The main indications for postmortem toxicological death cases since a comprehensive
toxicological investigation are suspicions, evaluation of clinical, circumstantial,
circumstances, or autopsy findings that toxicological, and autoptic data is the only
ESCTJ Vol. 10 No. (2) December, 2022 Bothina H. -1-
,REVIEW ARTICLE Systematic Review of Postmortem ……
possibility to assess the toxicological the stomach content of the victim using the
significance of a substance and to identify a Marsh test. However, Orfila discovered that
probable mechanism of death, which could the test had been inappropriately performed,
remain unclear despite an exhaustive analysis of and arsenic was later detected in the victim’s
all data existing (Giorgetti et al., 2020). body. Consequently, Marie was found guilty
of murder (Bertomeu-S´anchez and
2. Historical background According to NietoGalan, 2006).
the history of poisons written in an Egyptian In 1851, Jean Servais Stas developed
manuscript, Ebers Papyrus, approximately the first effective method for extracting
1500 BC, mandrake, hemlock, opium, alkaloids from biological
aconites, and certain metals from natural specimens.
sources were known for their poisonous Specifically, his method detected nicotine in
properties and they had been used as weapons postmortem specimens obtained from Gustave
or in torture. The Greeks used hemlock as a Fougnies, who was allegedly poisoned by his
means of state-sponsored execution, Socrates brother-in-law. The extraction procedure used
being the most famous case (Levine, 2020). by Stas was modified several years later by
A poison can be defined as any F.J. Otto. This method, which enabled the
substance that when taken in a sufficient isolation of purer alkaloid substances, became
quantity will cause intoxication or even death. known as the Stas–Otto method and remains
This dose-dependent relationship was first the basis for drug extraction to this day
explained by Paracelsus (1493–1541) with (Levine, 2020).
the statement “Sola dosisfacitvenenum” (only To analyze postmortem samples for a
dose determines the poison). For instance, wide variety of potential intoxicants, which
even the well-known deadly poison such as are unknown to the toxicologist in most cases,
cyanide (CN), arsenic, or carbon monoxide is a challenging task.
may not be harmful if it is inhaled or ingested 3. Postmortem toxicology challenges
in a minute quantity. On the other hand, To analyze postmortem samples for a
substances as harmless as drinking water or wide variety of potential intoxicants, which are
minerals such as potassium or sodium, if unknown to the toxicologist in most cases, is a
taken in excessive quantity, could induce challenging task. Moreover, there are several
death (Cheng, 2009). other factors (Söderberg, 2019): • Since
In 1814, Dr. MattheiuOrfila, a postmortem toxicology deals with deceased
Spanishborn French physician, and the subjects there is often a lack of information; the
chairman of the Legal Medicine Department initial suspicion for a drug in the first place is
at the Sorbonne made the first attempt to largely dependent on the circumstances
systematically study and categorize poisons. provided to the pathologist it might not be known
In his book “Traité des Poisons how much of a given drug was ingested (and not
ouToxicologieGenerale”, he established six even which drugs are suspected). Hospital
classes of poisons, basing the six classes records might be lacking or unavailable.
mainly on their toxic effects. The use of Circumstances surrounding the death might be
postmortem analysis as crucial evidence in unknown or unclear.
court can be dated back to 1840 when Dr. • The focus of the autopsy is both to exclude a
Orfila, was invited by the court to investigate morphological cause of death and investigate
the case of Marie LaFarge for the murder of pathological consequences of detected drugs
her husband using arsenic, a common poison and thus to provide guidance in an
used in those days. investigation
Before Orfila’s investigation, • One of the most important purposes of the
toxicological analysis of arsenic was found autopsy is to obtain samples for further
positive in the food but was not detected in investigation
ESCTJ Vol. 10 No. (2) December, 2022 Bothina H. -2-
,REVIEW ARTICLE Systematic Review of Postmortem ……
• The toxicology findings may not be reported mandatory in drug or poisoning deaths to
for several weeks after the body itself has establish:
been interred or cremated and the laboratory • Whether death is related to a drug or toxin or
results may be non-contributory. other cause (e.g. positional
4. Medicolegal applications of postmortem asphyxia/pneumonia, or a combination of
toxicological analysis both). • The pathological effects of drug or
According to Levine toxin use or misuse.
(2020), apostmortem toxicological • If any traumatic injuries were a consequence
analysis is needed in death cases where: of previous drug use.
a. The direct cause of death is suspected to be • If there was any natural disease that might
drug or poison-related e.g., intravenous drug have increased susceptibility to the effects of
deaths with observable recent a drug or toxin. • If the toxicity could have
injectanalysesion sites and oral intoxications been treated such as to prevent death.
indicated from a large number of unabsorbed • And to obtain suitable samples for
tablet fragments in the stomach toxicological analysis.
b. The cause of death is suspicious or unknown, 6. Information required prior to autopsy
a toxicology laboratory analysis is needed to According to guidelines of The Royal
identify and quantify the substances present in College of Pathologists (2018), before
the biological specimens in order to establish undertaking a post-mortem examination, the
a cause and/or manner of death (including pathologist should be briefed on any available
drug or poison-related). information. As the initial approach to the
c. Deaths other than drug intoxication, such as postmortem examination will depend on any
homicides and accidental deaths. A information provided and it is vital that the
toxicological analysis is needed to clarify the final report contains relevant details of the
manner of death, for the following reasons: history of the case and the source of the
• Many homicides are drug-related and the information.
abuse of drugs may provide a motive for the 6.1 Scene of death
homicide. This should include:
• In fatal traffic accidents, ascertain any • full details of the scene of death
influence of alcohol and/or drug(s) on the (indoors/outdoors, temperature, exposure).
driver. • how the body was found
• In arson deaths postmortem carbon monoxide • security of the scene
analysis can also be relevant. • place, posture, and clothing of the body
d. Involvement of drugs or poisons needs to be • presence/absence of needles, syringes,
ruled out to support negative pathological medicine containers, and pills
findings during autopsies; • provisional description of the body,
e. Toxicological analyses may even be important including injuries (if any) • identity of a
in deaths due to natural causes, as detected person discovering the dead person.
drugs may give clues as to any underlying 6.2 Circumstances of death
disease process, i.e., This should include:
anticonvulsant drugs, antidiabetic drugs, etc.; • witness statements.
f. When there is a statutory requirement for • previous medical history.
autopsies and subsequently toxicological • medical therapy regimen – current and
examinations are deemed necessary by an prior.
authority. • previous surgical operations and other
5. Role of the autopsy in toxicity-related interventions.
deaths • alcohol usage ± illicit drug use.
According to Ojanperä and Vuori • previous detention and date of release from
(2014), postmortem examination is prison.
ESCTJ Vol. 10 No. (2) December, 2022 Bothina H. -3-
, REVIEW ARTICLE Systematic Review of Postmortem ……
• if there are multiple deaths, the can be purchased and used for various
circumstances found at the scene should purposes including suicide. These agents may
direct the pathologist on which be colorless and odorless. A high level of
examinations are appropriate, which may suspicion is needed to detect them before
differ between the bodies, e.g. one death mortuary staff or others are exposed to lethal
may be drug-related, the other traumatic levels.
• known or suspected blood-borne virus In particular, if there is a history of
status, e.g. HIV, HBV, HCV cyanide ingestion or exposure to hydrogen
• family history. sulfide, extreme caution is required as the
• electrocardiogram (ECG), enzyme results cyanide is converted to the poisonous gas
and other pathological data, serum lipid hydrogen cyanide in the stomach, which may
profiles, and other biochemical tests. 6.3 be fatal if inhaled. It is worth noting that not
Possible sources of this information everyone can smell cyanide. In cases
Important information (and samples for involving toxic chemicals, the possibility of
further analysis) may be available from a environmental contamination should also be
variety of sources. However, common considered.
sources of this material are police, coroner’s However, if there is any doubt that the
officers, ambulance notes, general post-mortem can be conducted and the body
practitioners, hospital clinical notes, disposed of in a suitable way, the postmortem
laboratory results, family members, and should not be conducted, and the case should be
friends. 7. Health and safety precautions referred to an appropriately equipped mortuary
As stated by Saukko and Knight with the correct expertise to deal with such a
(2015a), mortuaries have their own local case. 8. Imaging
guidelines for dealing with potentially 8.1 Post-mortem imaging
hazardous or infectious cases and the In postmortem toxicology deaths imaging
approach taken in suspected drug deaths will help to determine the possibility of body
vary in line with these. In all cases, the packing, bone dense metaphyseal bands of lead
pathologist conducting the post-mortem lines, for the documentation of trauma, or for
should assess the risks posed by the case and other reasons peculiar to any particular case may
ensure the post-mortem is conducted in such be indicated in suspected drugrelated deaths
a way as to minimize any risk to the (Usui et al., 2017).
pathologist themselves and to all other parties In addition, the role of post-mortem
involved. Risk assessment is crucial, and the crosssectional imaging (PMCSI) is expanding as
use of personal protective equipment is experience and expertise in this field develop.
mandatory. Adequate mortuary ventilation is There is clear evidence to support the use of
also required and the use of downflow PMCSI in suspected drug-related deaths. If the
mortuary tables is recommended for high-risk history, scene examination, external
cases. examination, and laboratory results as well as the
7.1 Infections PMCSI images together support a diagnosis of
It should be remembered that drug-related death, then such a cause of death
intravenous drug users (IVDUs) are at an may be provided without the need for an invasive
increased risk of hepatitis, HIV, and post-mortem (Burke et al., 2012 and
tuberculosis, as well as opportunistic Winklhoferet al., 2014).
infections if their immune system is 8.2 Photography
compromised. 7.2 Chemicals It is highly desirable to have facilities
According to the guidelines of The available to photograph any findings of
Royal College of Pathologists (2018), many particular interest (Saukko and Knight, 2015a).
industrial activities involve the use of toxic
chemicals. In addition, a variety of chemicals
ESCTJ Vol. 10 No. (2) December, 2022 Bothina H. -4-
SYSTEMATIC REVIEW OF POSTMORTEM EXAMINATION IN
TOXICOLOGICAL FATALITIES
BY
ELPHAS SHIKOKOTI SIAYI (BSC. MLS)
Department of Medical Laboratory Sciences,, Faculty of Public Health, Masinde Muliro University of
science and technology,Kenya.
ABSTRACT
Postmortem examination in intoxicated deaths is required to establish the cause and manner of death. It
relies mainly on the identification of drugs or their known metabolites. This review provides a
comprehensive account of toxicological fatalities involving investigative data, autopsy findings, analytical
methods, and toxicological results. Postmortem diagnosis of fatal intoxications is complicated. Autopsy
findings indicative of an intoxication-related death are scarce and mostly unspecific. Instead, the diagnosis
is more dependent on the circumstances surrounding death, and on the toxicological results. The collection
of specimens is the first and most important step in the toxicological examination as the proper biological
specimens can maximize the chance of obtaining meaningful analytical findings. Since deterioration of
specimens increases with postmortem time interval, biological specimens should be collected as soon as
possible after death. Additionally, the collection of specimens after the autopsy is rarely possible. To
correctly evaluate the toxicological results, the forensic investigator needs to separate between the lethal and
non-lethal concentrations. While a wealth of scientific data exists concerning concentrations and effects in
experimental animals and in living human subjects, these data cannot simply be translated into postmortem
concentrations. Due to various changes occurring in the early phase after death, the postmortem
concentration of a substance often does not mirror the concentration antemortem.
In conclusion, it is important to correlate the clinical and autopsy findings with the toxicology results to
appropriately evaluate toxicological deaths. Postmortem reference values are needed, and more studies
should be hired for the establishment of postmortem reference concentrations.
Keywords: Autopsy, Intoxication deaths, Sampling, Reference values.
E. mail: suggest poisoning. A toxicological
investigation should also be performed in
1. Introduction he legal basis for a cases of homicides, traffic accidents,
T medicolegal cause of death occupational accidents, suspicions of
investigation differs between malpractice, and where the immediate cause
countries. The investigation is usually of death is unknown following an autopsy.
started by the police, who seek the expertise The deaths of known drug and alcohol abusers
of the authority in charge of forensic are often associated with accidental or suicidal
medicine, often resulting in an autopsy overdoses. A toxicological investigation is
performed by a forensic pathologist or a desirable in all cases involving children and
medical examiner (Hanzlick, 2007). The young adults, regardless of their apparent cause
medicolegal autopsy rate varies greatly of death (Di Candia et al., 2022).
between countries, from a few percent to over Postmortem toxicological investigations
20% of all deaths. have traditionally been used to resolve
Likewise, the rate of postmortem individual cases. However, postmortem
toxicological investigations depends on a toxicology can serve society in a broader sense
multitude of factors. These include by contributing to death statistics and scientific
differences between types of postmortem studies, as in studies on drugs related to motor
cases and between requests from individual vehicle crashes (Mørland et al., 2011).
forensic pathologists and medical examiners A precise post-mortem examination is a
(Ojanperä and Vuori, 2014). fundamental part of the evaluation of
The main indications for postmortem toxicological death cases since a comprehensive
toxicological investigation are suspicions, evaluation of clinical, circumstantial,
circumstances, or autopsy findings that toxicological, and autoptic data is the only
ESCTJ Vol. 10 No. (2) December, 2022 Bothina H. -1-
,REVIEW ARTICLE Systematic Review of Postmortem ……
possibility to assess the toxicological the stomach content of the victim using the
significance of a substance and to identify a Marsh test. However, Orfila discovered that
probable mechanism of death, which could the test had been inappropriately performed,
remain unclear despite an exhaustive analysis of and arsenic was later detected in the victim’s
all data existing (Giorgetti et al., 2020). body. Consequently, Marie was found guilty
of murder (Bertomeu-S´anchez and
2. Historical background According to NietoGalan, 2006).
the history of poisons written in an Egyptian In 1851, Jean Servais Stas developed
manuscript, Ebers Papyrus, approximately the first effective method for extracting
1500 BC, mandrake, hemlock, opium, alkaloids from biological
aconites, and certain metals from natural specimens.
sources were known for their poisonous Specifically, his method detected nicotine in
properties and they had been used as weapons postmortem specimens obtained from Gustave
or in torture. The Greeks used hemlock as a Fougnies, who was allegedly poisoned by his
means of state-sponsored execution, Socrates brother-in-law. The extraction procedure used
being the most famous case (Levine, 2020). by Stas was modified several years later by
A poison can be defined as any F.J. Otto. This method, which enabled the
substance that when taken in a sufficient isolation of purer alkaloid substances, became
quantity will cause intoxication or even death. known as the Stas–Otto method and remains
This dose-dependent relationship was first the basis for drug extraction to this day
explained by Paracelsus (1493–1541) with (Levine, 2020).
the statement “Sola dosisfacitvenenum” (only To analyze postmortem samples for a
dose determines the poison). For instance, wide variety of potential intoxicants, which
even the well-known deadly poison such as are unknown to the toxicologist in most cases,
cyanide (CN), arsenic, or carbon monoxide is a challenging task.
may not be harmful if it is inhaled or ingested 3. Postmortem toxicology challenges
in a minute quantity. On the other hand, To analyze postmortem samples for a
substances as harmless as drinking water or wide variety of potential intoxicants, which are
minerals such as potassium or sodium, if unknown to the toxicologist in most cases, is a
taken in excessive quantity, could induce challenging task. Moreover, there are several
death (Cheng, 2009). other factors (Söderberg, 2019): • Since
In 1814, Dr. MattheiuOrfila, a postmortem toxicology deals with deceased
Spanishborn French physician, and the subjects there is often a lack of information; the
chairman of the Legal Medicine Department initial suspicion for a drug in the first place is
at the Sorbonne made the first attempt to largely dependent on the circumstances
systematically study and categorize poisons. provided to the pathologist it might not be known
In his book “Traité des Poisons how much of a given drug was ingested (and not
ouToxicologieGenerale”, he established six even which drugs are suspected). Hospital
classes of poisons, basing the six classes records might be lacking or unavailable.
mainly on their toxic effects. The use of Circumstances surrounding the death might be
postmortem analysis as crucial evidence in unknown or unclear.
court can be dated back to 1840 when Dr. • The focus of the autopsy is both to exclude a
Orfila, was invited by the court to investigate morphological cause of death and investigate
the case of Marie LaFarge for the murder of pathological consequences of detected drugs
her husband using arsenic, a common poison and thus to provide guidance in an
used in those days. investigation
Before Orfila’s investigation, • One of the most important purposes of the
toxicological analysis of arsenic was found autopsy is to obtain samples for further
positive in the food but was not detected in investigation
ESCTJ Vol. 10 No. (2) December, 2022 Bothina H. -2-
,REVIEW ARTICLE Systematic Review of Postmortem ……
• The toxicology findings may not be reported mandatory in drug or poisoning deaths to
for several weeks after the body itself has establish:
been interred or cremated and the laboratory • Whether death is related to a drug or toxin or
results may be non-contributory. other cause (e.g. positional
4. Medicolegal applications of postmortem asphyxia/pneumonia, or a combination of
toxicological analysis both). • The pathological effects of drug or
According to Levine toxin use or misuse.
(2020), apostmortem toxicological • If any traumatic injuries were a consequence
analysis is needed in death cases where: of previous drug use.
a. The direct cause of death is suspected to be • If there was any natural disease that might
drug or poison-related e.g., intravenous drug have increased susceptibility to the effects of
deaths with observable recent a drug or toxin. • If the toxicity could have
injectanalysesion sites and oral intoxications been treated such as to prevent death.
indicated from a large number of unabsorbed • And to obtain suitable samples for
tablet fragments in the stomach toxicological analysis.
b. The cause of death is suspicious or unknown, 6. Information required prior to autopsy
a toxicology laboratory analysis is needed to According to guidelines of The Royal
identify and quantify the substances present in College of Pathologists (2018), before
the biological specimens in order to establish undertaking a post-mortem examination, the
a cause and/or manner of death (including pathologist should be briefed on any available
drug or poison-related). information. As the initial approach to the
c. Deaths other than drug intoxication, such as postmortem examination will depend on any
homicides and accidental deaths. A information provided and it is vital that the
toxicological analysis is needed to clarify the final report contains relevant details of the
manner of death, for the following reasons: history of the case and the source of the
• Many homicides are drug-related and the information.
abuse of drugs may provide a motive for the 6.1 Scene of death
homicide. This should include:
• In fatal traffic accidents, ascertain any • full details of the scene of death
influence of alcohol and/or drug(s) on the (indoors/outdoors, temperature, exposure).
driver. • how the body was found
• In arson deaths postmortem carbon monoxide • security of the scene
analysis can also be relevant. • place, posture, and clothing of the body
d. Involvement of drugs or poisons needs to be • presence/absence of needles, syringes,
ruled out to support negative pathological medicine containers, and pills
findings during autopsies; • provisional description of the body,
e. Toxicological analyses may even be important including injuries (if any) • identity of a
in deaths due to natural causes, as detected person discovering the dead person.
drugs may give clues as to any underlying 6.2 Circumstances of death
disease process, i.e., This should include:
anticonvulsant drugs, antidiabetic drugs, etc.; • witness statements.
f. When there is a statutory requirement for • previous medical history.
autopsies and subsequently toxicological • medical therapy regimen – current and
examinations are deemed necessary by an prior.
authority. • previous surgical operations and other
5. Role of the autopsy in toxicity-related interventions.
deaths • alcohol usage ± illicit drug use.
According to Ojanperä and Vuori • previous detention and date of release from
(2014), postmortem examination is prison.
ESCTJ Vol. 10 No. (2) December, 2022 Bothina H. -3-
, REVIEW ARTICLE Systematic Review of Postmortem ……
• if there are multiple deaths, the can be purchased and used for various
circumstances found at the scene should purposes including suicide. These agents may
direct the pathologist on which be colorless and odorless. A high level of
examinations are appropriate, which may suspicion is needed to detect them before
differ between the bodies, e.g. one death mortuary staff or others are exposed to lethal
may be drug-related, the other traumatic levels.
• known or suspected blood-borne virus In particular, if there is a history of
status, e.g. HIV, HBV, HCV cyanide ingestion or exposure to hydrogen
• family history. sulfide, extreme caution is required as the
• electrocardiogram (ECG), enzyme results cyanide is converted to the poisonous gas
and other pathological data, serum lipid hydrogen cyanide in the stomach, which may
profiles, and other biochemical tests. 6.3 be fatal if inhaled. It is worth noting that not
Possible sources of this information everyone can smell cyanide. In cases
Important information (and samples for involving toxic chemicals, the possibility of
further analysis) may be available from a environmental contamination should also be
variety of sources. However, common considered.
sources of this material are police, coroner’s However, if there is any doubt that the
officers, ambulance notes, general post-mortem can be conducted and the body
practitioners, hospital clinical notes, disposed of in a suitable way, the postmortem
laboratory results, family members, and should not be conducted, and the case should be
friends. 7. Health and safety precautions referred to an appropriately equipped mortuary
As stated by Saukko and Knight with the correct expertise to deal with such a
(2015a), mortuaries have their own local case. 8. Imaging
guidelines for dealing with potentially 8.1 Post-mortem imaging
hazardous or infectious cases and the In postmortem toxicology deaths imaging
approach taken in suspected drug deaths will help to determine the possibility of body
vary in line with these. In all cases, the packing, bone dense metaphyseal bands of lead
pathologist conducting the post-mortem lines, for the documentation of trauma, or for
should assess the risks posed by the case and other reasons peculiar to any particular case may
ensure the post-mortem is conducted in such be indicated in suspected drugrelated deaths
a way as to minimize any risk to the (Usui et al., 2017).
pathologist themselves and to all other parties In addition, the role of post-mortem
involved. Risk assessment is crucial, and the crosssectional imaging (PMCSI) is expanding as
use of personal protective equipment is experience and expertise in this field develop.
mandatory. Adequate mortuary ventilation is There is clear evidence to support the use of
also required and the use of downflow PMCSI in suspected drug-related deaths. If the
mortuary tables is recommended for high-risk history, scene examination, external
cases. examination, and laboratory results as well as the
7.1 Infections PMCSI images together support a diagnosis of
It should be remembered that drug-related death, then such a cause of death
intravenous drug users (IVDUs) are at an may be provided without the need for an invasive
increased risk of hepatitis, HIV, and post-mortem (Burke et al., 2012 and
tuberculosis, as well as opportunistic Winklhoferet al., 2014).
infections if their immune system is 8.2 Photography
compromised. 7.2 Chemicals It is highly desirable to have facilities
According to the guidelines of The available to photograph any findings of
Royal College of Pathologists (2018), many particular interest (Saukko and Knight, 2015a).
industrial activities involve the use of toxic
chemicals. In addition, a variety of chemicals
ESCTJ Vol. 10 No. (2) December, 2022 Bothina H. -4-
