FOLLOW-UP INVESTIGATIONS CORONER'S INVESTIGATION The Office of the Sheriff-Coroner of Contra Costa County (hereinafter "Coroner") conducted an investigation of Kiefer's death (Case No. According to the Coroner's report, Kiefer's death was reported to the Coroner at 9:05 AM on February 3, 1993. The time of death is listed as 8:20 AM and the cause of death classified as "natural." In the section concerning Kiefer's medical history, the report states: "Acute exacerbation of chronic paranoia schizophrenia -- meds -- Thorazine, Ativan, Benadryl, Haldol," and then refers the reader to the medical records for further information. The investigation report states: "[t]his report concerns the death of a 38 year old male that died at East Bay Hospital (Intensive Care Unit Second Floor Seclusion Room)." The report notes that Kiefer had no significant medical history except for treatment of his mental disability. The Coroner's investigation report further stated: [Psychiatrist #1] admitted Marc on a 72 hour hold for psychiatric care and was admitted to the locked intensive care unit. Marc was highly agitated and confused and said that he had used crack cocaine in the recent past. The toxicology test proved negative. Marc had to be placed in four point restraints because of his marked agitated confused state of mind, and hyperverbal condition, for his own safety. Marc was placed in the restraints at approx. 0100 hrs this morning. Marc was in the seclusion room by himself and checked on by the staff approx. every fifteen to twenty minutes. Marc was last seen alive by staff at approx. 0730 hrs. Marc was diccovered [sic] unresponsive at 0747 hrs and was pronounced dead by [Psychiatrist #1] at 0820 hrs. An autopsy was performed by a forensic pathologist, on February 4, 1993, at 12:30 PM. The autopsy report lists Kiefer's diagnoses as: Chronic schizophrenia (by history)
toxicological services when, as was the situation with Kiefer, poisoning or drug toxicity may be causing the person's decompensation. Toxicological training, education, and policy development for EBH physicians should address: (1) the criteria necessary for the initiation of a comprehensive toxicological evaluation; (2) the importance of obtaining urine samples when a maximum amount of information is needed in a short time frame; and (3) how to interpret results (e.g., the absence of certain drugs or poisons may be as significant as their presence). See, e.g., Bradford, et al., "Role of the Toxicology Laboratory in the Treatment of Acute Poisoning," Concepts in Toxicology Review (1986). As explained by the forensic toxicologist PAI consulted: The fact that the patient's initial screen for three street drugs was negative should not have ended the inquiry. At least by the time Kiefer continued to deteriorate at East Bay, those previous negative test results should have raised the issue of whether he was toxic on other substances, especially prescribed medications. Physician education should focus on reversing the dangerous assumption that a medical (as opposed to "psychiatric") condition is not playing a factor in the decompensation of a mentally disabled person. As emphasized by the psychiatrist PAI consulted, in order to help avoid dangerous misdiagnosis: "In cases of acute psychotic decompensation, it is important to consider medical causes. Medical causes for such decompensation can include everything from drug toxicity to malignancies." According to all of the psychiatrists PAI conferred with, as well as the literature, physician education regarding the emergency treatment of acute psychosis and agitation should increase clinicians' skills to implement a simultaneous three-pronged effort on behalf of the mentally disabled person: (1) ensuring the individual's safety; (2) conducting needed assessments and laboratory testing to determine the cause of the agitation (i.e., in this situation, anticholinergic drug toxicity); and (3) initiating appropriate treatment. See, e.g., Sanders, Kathy M., M.D., "Emergency Treatment of Acute Psychosis and Agitation," Guest Transcript, Practical Reviews in Psychiatry, Volume 17, Number IX, December 1993.