Chief Medical Examiner's Death Review

A CPSM medical consultant attends the monthly Adult Inquest Review Committee meetings at the Chief Medical Examiners’ Office to review deaths involving prescription medications. All methadone and buprenorphine/naloxone (Suboxone) deaths undergo detailed review as well. All prescribers involved receive a standard cover letter plus a summary of the ME report, along with feedback on prescribing practices noted.


Feedback can be divided into 3 categories:

·         FYI

·         Prescribing falls outside of guidelines endorsed by the CPSM

(Feedback is given utilizing standardized evidence-based quality indicators, e.g. concomitant prescribing of opioids and benzodiazepines); includes resources

·         Significant concerns (rare)


Three Themes have been identified from this review process:

v  Deaths involving polypharmacy where all prescriptions were written by a single physician.

v  Deaths involving multiple sedating medications (often including an opioid and more than one benzodiazepine at a time) prescribed to the same patient by different physicians; filled at multiple different pharmacies.

v  OTC medication use combined with Rx medication (often polypharmacy) increases overdose risk.