A drug can appear frequently in a set of fatal cases without having acted alone in those deaths. A New South Wales coronial study illustrates why the case definition and the number of contributors matter.
What the series included
The authors reviewed coronial records for 495 unintentional drug-related deaths among people with mental illness from 2012 to 2016. Diazepam was the most frequently involved substance in the study’s male and female groups. Four out of five cases included more than one contributory drug.
How to use the finding in a case review
The study counted selected deaths. It did not compare people taking diazepam with a matched group who did not take it. A reviewer should distinguish a drug detected on the laboratory report from a drug listed as contributory by the coroner. To assess a particular death, obtain the reported concentrations and specimens, scene and treatment records, and the coroner’s reasoning for each listed contributor.
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