Girela et al.: Death Certification of Problem Drinkers 233

Death Certification of Problem Drinkers E GIRELA, MD Lecturer in Legal Medicine and Toxicology, University of Granada

E LACHICA, MD PhD Senior Lecturer in Legal Medicine and Toxicology, University of Cordoba

D POUNDER, MB MRCPath Professor of Forensic Medicine, Department of Forensic Medicine, Dundee Royal Infirmary, Dundee DDt 9ND, Scotland INTRODUCTION

Epidemiological studies of alcohol-related mortality commonly rely on official cause of death data derived from death certificates. Such data is widely accepted as under-estimating alcoholrelated mortality (Maxwell, 1986), but the extent to which the data is deficient is largely unknown. In this study we describe the extent of underreporting of alcohol-related mortality in deaths subject to medico-legal investigation in a mixed urban-rural population in Scotland. MATERIALS AND METHODS

A consecutive, retrospective series of 1,000 medico-legal death investigations were selected from the files of the University Department of Forensic Medicine, Dundee. The 1,000 fatalities included 44 children under the age of 15 years who were excluded from further study. The series represents all fatalities investigated by procurators fiscal within the administrative regions of Tayside and North Fife from 2 November, 1988 to 31 May, 1990. The estimated mid-year population (1989) of the area was 460,760, including the city of Dundee with a population of 172,540. In 1989 this area accounted for 7.8 per cent of all deaths investigated by procurators fiscal in Scotland (8,248) which in turn represented 12.7 per cent of all deaths for that year (65,017).

The departmental case files were reviewed for evidence that the deceased was a problem drinker. The files include the autopsy report, a photocopy of the death certificate, a copy of the police report to the procurator fiscal, abstracts of hospital records reviewed by the pathologist, records of telephone inquiries to general practi tioners, and the results of blood alcohol and other toxicological studies. The information contained in the files was available to the pathologist at the time of death certification. Also included in the files is the pathologist's opinion on manner of death (natural, accident, suicide, homicide, unclassified or undetermined). A decedent was accepted as a problem drinker if the hospital, general practitioner, or police reports described the person as a 'chronic alcoholic', 'heavy drinker', or as having 'drink/alcohol problems', or if the autopsy showed pathological evidence of alcohol-specific disease, or if the blood alcohol concentration was excessive, i.e. greater than 250mg per cent. This blood alcohol concentration was selected because it is widely accepted in British forensic practice as the minimum lethal concentration. Age, sex and body weight matched 'nonproblem drinker' controls were randomly selected from amongst the 1,000 cases. The organ weights, and the organ weights corrected for body surface area (BSA) and body mass

234 Moo. Sci. Law (1992) Vol. 32, NO.3

index (EMI), of the two groups were compared using a student t-test. RESULTS

Amongst the 956 fatalities over 15 years of age there were 139 problem drinkers (14 per cent) of which 100 were male and 39 female. The mean age was 51.3 years (range 22 to 87 years). 13 persons had a blood alcohol concentration greater than 250mg per cent (range 254--411mg per cent) as the only evidence of problem drinking (these included 5 accidents and 3 suicides) A further 44 persons with other evidence of problem drinking (35 per cent) had blood alcohol concentrations ranging from 51 to 570mg per cent. In all 57 (41 per cent) of the problem drinkers had blood alcohol concentrations over 50mg per cent at the time of death. 32 of the non-problem drinkers had blood alcohol concentrations over 50mg per cent (range 62245mg per cent) but analysis for alcohol was carried out in only a minority of these 817 deaths. Acute or chronic alcoholism was mentioned on the death certificate in 51 of the 139 cases (36.7 per cent) and the cause of death given would likely be interpreted as alcohol-related in a further 11 cases (7.9 per cent), leaving an

under-estimate of mortality in problem drinkers of 77 cases (55.4 per cent). 'Chronic alcoholism' appeared on 28 death certificates, and 'acute alcoholism' or 'acute alcohol poisoning' on 23. Causes of death in the further 11 cases likely to be interpreted as alcohol-related included acute metabolic derangement and cirrhosis, congestive cardiomyopathy, ruptured oesophageal varices and cirrhosis. Amongst these 62 cases in which certification indicated that death was alcoholrelated, there were 36 natural deaths, 20 accidents, 5 suicides and one homicide. In the remaining 77 cases, certification gave no indication that the death was alcohol-related. In this group there were 48 natural deaths, 13 accidents, 14 suicides, one homicide and one instance of undetermined manner of death. In total, there were 19 suicides (13.7 per cent) among the 139 problem drinkers, representing 18.5 per cent of all suicides (numbering 103) in the 956 fatalities. Of the 139 cases, 110 (79 per cent) were subject to autopsy, the remainder being certified after an external examination of the body (the Scottish so-called 'view and grant' procedure). The 110 cases subject to autopsy comprised 78 males and 32 females. The height,

Table I. Organ Weight (mean e SD)

Problem drinkers Body height (ern) Body weight (kg) Liver (g) Liver;BSA Liver;BMI Kidneys (g) Kidneys;BSA Kidneys;BMI Spleen (g) Spleen;BSA Spleen;BMI

167.1 ± 9.2 67.3 ± 16.4 1,694.0 ± 474.0 968.5 ± 218.8 72.0 ± 17.7 306.2 ± 73.1 175.0 ± 33.0 13.1 ± 3.2 129.0 ± 64.9 73.5 ± 34.8 5.43± 2.56

Controls 168.6 ± 9.2 69.7 ± 15.2 1,633.0 ± 397.0 913.6 ± 201.0 68.0 ± 16.8 292.6 ± 78.3 162.7 ± 33.6 12.1 ± 2.8 158.1 ± 80.1 87.4 ± 39.2 2.72 6.44±

BMI = body weight in k~(height in m) 2 BSA = (weight in kg) 0.4 5 x (height in em) 0.725 x 0.007184

(n.s.)

(p = 0.055) (n.s.) (n.s.)

(p < (p < (p < (p < (p

Death certification of problem drinkers.

Girela et al.: Death Certification of Problem Drinkers 233 Death Certification of Problem Drinkers E GIRELA, MD Lecturer in Legal Medicine and Toxico...
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