David Ranson

Homicide-suicide in Victoria, Australia

Thirty-nine incidents of homicide-suicide occurring in Victoria, Australia between 1985 and 1989 were examined. In 33 cases the assailants were men. The victims were spouses or women living in a de facto marriage. The majority of the victims were shot, and this was also the most frequent method of suicide. Breakdown in a relationship was the most frequent reason for killing. Mental illness of the assailant accounted for the killing in approximately 20% of cases. Physical ill health and financial stress were identified as important associative factors, particularly in the elderly. The pattern of homicide-suicide in Victoria is similar to that observed in other jurisdictions and represents an important and distinct subgroup of homicide.

Sudden Death and Benzodiazepines

A study of 16 deaths associated with toxic concentrations of benzodiazepines during the period of 5 years leading up to July 1994 is presented. Cases where other drugs, including ethanol, had contributed to the death were excluded. All cases were subject to a full macroscopic and microscopic examination by pathologists, and all cases were subject to a full toxicological work-up. Preexisting natural disease was a feature of 11 cases. In the remaining five cases, death was caused solely by benzodiazepines. There were 14 suicides. Nitrazepam and temazepam were the most prevalent drugs detected, followed by oxazepam and flunitrazepam. Minimum toxic femoral blood concentrations of 7-aminonitrazepam, 7-aminoflunitrazepam, and oxazepam were estimated as 0.5, 0.2, and 2 mg/L, respectively. Relating these deaths to prescription rates in Victoria suggest that flunitrazepam may be inherently more toxic if misused than other benzodiazepines currently available on the Australian market.

Resident-to-resident physical aggression leading to injury in nursing homes: a systematic review

BACKGROUND resident-to-resident aggression (RRA) is an understudied form of elder abuse in nursing homes. OBJECTIVE the purpose of this systematic review was to examine the published research on the frequency, nature, contributing factors and outcomes of RRA in nursing homes. METHODS in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement, this review examined all original, peer-reviewed research published in English, French, German, Italian or Spanish between 1st January 1949 and 31st December 2013 describing incidents of RRA in nursing homes. The following information was extracted for analysis: study and population characteristics; main findings (including prevalence, predisposing factors, triggers, nature of incidents, outcomes and interventions). RESULTS eighteen studies were identified, 12 quantitative and 6 qualitative. The frequency of RRA ranged from 1 to 122 incidents, with insufficient information across the studies to calculate prevalence. RRA commonly occurred between exhibitors with higher levels of cognitive awareness and physical functionality and a history of aggressive behaviours, and female targets who were cognitively impaired with a history of behavioural issues including wandering. RRA most commonly took place in the afternoon in communal settings, was often triggered by communication issues and invasion of space, or was unprovoked. Limited information exists on organisational factors contributing to RRA and the outcomes for targets of aggression. CONCLUSIONS we must continue to grow our knowledge base on the nature and circumstances of RRA to prevent harm to an increasing vulnerable population of nursing home residents and ensure a safe working environment for staff.

A community-based model of rapid autopsy in end-stage cancer patients

To the Editor: Systematic genomic studies, including the Cancer Genome Atlas (TCGA)1 and the International Cancer Genome Consortium (ICGC)2, have provided an unprecedented catalog of driver mutations in human cancer. However, these studies use mainly primary, pre-treatment tumor material obtained at surgery with curative intent. There is an urgent need to identify and characterize resistance mechanisms to understand how cancers can evade even the best medical efforts and kill patients; therefore, access to end-stage disease is important. Solid cancers show considerable spatial3, temporal4,5 and genomic heterogeneity at diagnosis. Selective pressure and mutagenic impact of treatment6 drives intra-patient evolution of cancer cell populations4,7. Understanding acquired resistance requires access to paired preand post-treatment samples4,7; however, curative surgery is typically confined to patients with locoregional disease, and opportunities for tumor sampling in advanced disseminated disease are limited. Here, we describe Cancer Tissue Collection After Death (CASCADE), an autopsy program that overcomes logistical challenges to enable collection of samples at end stage for research in melanoma and breast, ovarian and prostate cancers. For the CASCADE study, we aimed to recruit cancer patients close to the end of life, including those outside the minority of patients who die in hospitals. To preserve tissue integrity, autopsies must commence within a few hours of death, requiring access to around-the-clock services. Intervention in the emotionally charged end-of-life environment must be managed in an ethical manner and to a high standard. Finally, we aimed for the study to be highly cost-effective. We believe our approach to meeting these challenges is applicable to researchers in other large urban centers. Here we summarize the main steps in CASCADE’s operating protocol and our experiences from the initial 3 years and 30 autopsies performed (Fig. 1). Information about institutional review board approvals (including a detailed patient informationand-consent form), the autopsy procedure and certain laboratory processes is given in Supplementary Methods and Supplementary Figure 1. Recruitment of participants was led by the clinicians. Such discussions require careful consideration, in timing and in language, and were initiated only if there was a perception that tissue donation would be acceptable to the patients and their families. Factors suggesting acceptability include the emotional stability of the participant and family members and their clarity about and acceptance of the terminal nature of the disease. On occasion, participants prompted discussion by asking about organ or body donation. Consent discussions typically involved oncologists and/or palliative care physicians employed at recruiting hospitals who had established a care relationship with the participant and their family during the patient’s cancer journey. Frequently, the study was introduced at one meeting and discussed over several subsequent clinic visits, allowing patients and their families time to consider participation. We view the involvement of family members in the consent process as essential to support the participant and facilitate decisionmaking. Involvement of family members also ensures that they are fully aware of the autopsy process and helps to clarify funeral arrangements for the study team. After obtaining consent, study investigators collated clinical information, including that related to past and current treatment and diagnostic procedures such as imaging, on an ongoing basis. Between September 2012 and August 2015, 40 patients were approached, and 37 (92.5%) expressed interest in participating. Of those 32 patients (80%) consented; the other 5 had rapid clinical deterioration precluding

Nature and Extent of External-Cause Deaths of Nursing Home Residents in Victoria, Australia

To describe the nature and extent of external‐cause deaths of residents of nursing homes in Victoria, Australia.

The utility of medico-legal databases for public health research: a systematic review of peer-reviewed publications using the National Coronial Information System.

BackgroundMedico-legal death investigations are a recognised data source for public health endeavours and its accessibility has increased following the development of electronic data systems. Despite time and cost savings, the strengths and limitations of this method and impact on research findings remain untested. This study examines this issue using the National Coronial Information System (NCIS).MethodsPubMed, ProQuest and Informit were searched to identify publications where the NCIS was used as a data source for research published during the period 2000–2014. A descriptive analysis was performed to describe the frequency and characteristics of the publications identified. A content analysis was performed to identify the nature and impact of strengths and limitations of the NCIS as reported by researchers.ResultsOf the 106 publications included, 30 reported strengths and limitations, 37 reported limitations only, seven reported strengths only and 32 reported neither. The impact of the reported strengths of the NCIS was described in 14 publications, whilst 46 publications discussed the impacts of limitations. The NCIS was reported to be a reliable source of quality, detailed information with comprehensive coverage of deaths of interest, making it a powerful injury surveillance tool. Despite these strengths, researchers reported that open cases and missing information created the potential for selection and reporting biases and may preclude the identification and control of confounders.ConclusionsTo ensure research results are valid and inform health policy, it is essential to consider and seek to overcome the limitations of data sources that may have an impact on results.

Fly pupae and puparia as potential contaminants of forensic entomology samples from sites of body discovery

Fly pupae and puparia may contaminate forensic entomology samples at death scenes if they have originated not from human remains but from animal carcasses or other decomposing organic material. These contaminants may erroneously lengthen post-mortem interval estimates if no pupae or puparia are genuinely associated with the body. Three forensic entomology case studies are presented, in which contamination either occurred or was suspected. In the first case, blow fly puparia collected near the body were detected as contaminants because the species was inactive both when the body was found and when the deceased was last sighted reliably. The second case illustrates that contamination may be suspected at particularly squalid death scenes because of the likely presence of carcasses or organic material. The third case involves the presence at the body discovery site of numerous potentially contaminating animal carcasses. Soil samples were taken along transects to show that pupae and puparia were clustered around their probable sources.

Premature deaths of nursing home residents: an epidemiological analysis

Objectives: To conduct a descriptive epidemiological analysis of external cause deaths (premature, usually injury‐related, and potentially preventable) of nursing home residents in Australia.

Issues in child homicides: 11 cases

For a variety of reasons, child homicides are the most difficult cases for forensic pathologists. For example, the events are usually not witnessed, accidental explanations are offered, often there is more than one carer spanning the period over which the injuries might have occurred and there can be conflicting opinions between the various medical specialities. Eleven cases of fatal child abuse are presented to illustrate and briefly discuss particular difficulties. Reference is also made to interaction with the legal process and parallel difficulties the law has with fatal child abuse.

Causes of death determined in medicolegal investigations in residents of nursing homes: a systematic review.

To systematically review published research characterizing the nature and circumstances surrounding the death of older people in nursing homes specifically using information generated for medicolegal death investigations.