The Milwaukee County Medical Examiner’s Office performed an evidence-based review of natural deaths certified without autopsy or toxicology testing. 315 such cases from 2020 and 2021 were selected. This study reviewed the deaths to determine if the cause of death was drug-related versus natural disease. Blood samples were screened by liquid chromatography-quadrupole mass spectrometry with time-of-flight detection, a high-resolution mass spectrometry technique. The analytes detected were evaluated for contribution to the cause resulting in a change in manner of death from natural to accident or suicide. Confirmatory analysis was performed where appropriate and results were reported to the forensic pathologist for evaluation and amendment of the death certificate as appropriate. As a result of the screening and confirmatory work, 18 cases (5.7%) were identified where significant drugs were detected and thus the cause and manner of death were amended. One case was amended from natural to suicide after a conversation with the family about the toxicology findings, and the remaining cases were amended to a manner of accident. The confirmed substances that were deemed responsible for the deaths included both prescription medications and illicit drugs. These findings suggest that appropriate toxicology screening will assist with determination of cause and manner of death, even in cases that may have not been traditionally examined
