Cause-of-death challenges in arrest-related deaths

Say goodbye to “positional asphyxia” and hello to genetic cardiac testing

Arrest-related deaths (ARDs) usually occur in chronic stimulant drug users who had been exhibiting bizarre or violent behavior before the police are called. These individuals do not feel fatigue or pain. Unless they are quickly sedated, they may continue exerting themselves until they die. Unfortunately, it is the job of police to restrain them until EMS can sedate them – hopefully in time. This is still a relatively uncommon event for any given agency, as only 1:1000 resistant arrests ends in a death. (That rate goes down to 1:3000 when electrical weapons are used.)

The law (in most states) requires that all ARDs be investigated by the local Medical Examiner (ME), who must be a physician, and who signs the death certificate. In many jurisdictions, a coroner (often elected, and only rarely an MD) issues a death certificate. The certificate always specifies the cause of death (COD) and also the “manner of death,” a term which means roughly the same thing as “circumstance of death.” The COD is usually somewhat scientific, depending on the competence of the physician. Determining the manner of death is often arbitrary.

Cause of Death

At the last National Association of Medical Examiners meeting, Steven Karch, MD, presented on “Sudden Death During Law Enforcement Restraint” with the goal of helping improve diagnosis of a non-firearm ARD (arrest-related-death). Karch is an internationally respected cardiac pathologist and expert on the effects of illegal drugs. He has written leading textbooks on drug abuse such as the 1267-page treatise “Drug Abuse Handbook.”

The themes of his presentation were:

  1. In about one-third of the cardiac arrests in the young (including athletes) we cannot find an anatomical cause. Translation: Don’t automatically blame the police just because you cannot find an obviously bad heart.
  2. Many sudden deaths are due to genetic electrical abnormalities such as QT prolongation, which is something you will not find by simply cutting the body open. Many refer to this as the “molecular” autopsy, because the abnormality causing death is at the molecular level, not visible to even with a microscope. [1]
  3. Prone restraint and “positional asphyxia” have been thoroughly and repeatedly scientifically debunked as a cause of an ARD. Why are we still using this silly junk science to sometimes blame law enforcement? [2,3]

“The really big news is that multiple controlled prospective studies have performed genetic testing in cases of sudden cardiac death where the autopsy was essentially negative. Depending on the study, 20-30 percent of decedents with normal appearing hearts were found to have lethal cardiac genetic mutations,” Dr. Karch told Police1.

Note: the molecular autopsy (genetic cardiac testing) is expensive and almost certainly the ME has no way to pay for it. Yet without this testing, the autopsy is incomplete, leaving the ME or coroner unable to complete the certificate. Many, if not most officials are unaware of these genetic abnormalities, so they fudge the manner by including some useless verbiage, such as “died while fighting with police” or died after the use of an electrical weapon (even though the shock was administered 15 minutes earlier and humans, unlike eels do not store electricity!). As a consequence police officers have been sued or criminal charged – so your department should offer to pay for the testing.

Note: We still have a problem with lethal cardiomyopathies and other cardiac abnormalities that are visible with tissue samples under a microscope. Forensic pathology residencies do not require any special training in heart disease, and an ME may write off obvious cardiac abnormalities because they are simply ignorant of their significance. For example, an enlarged heart greatly increases the chances of sudden death, but don’t count on your ME knowing that, or assume that the heart has been properly examined. A cardiac pathologist consult is highly recommended with an ARD.

Manner of Death

The reason an MOD is required is that under old English law (dating back to 1194), if you died by suicide, the inheritance tax was 100%, while an accidental or natural death meant the inheritance tax was 0. The Crown’s inheritance-tax ruler was the “crowner,” which became the “coroner.”

The MOD is selected from the following causes:

  1. Natural
  2. Accidental
  3. Undetermined
  4. Homicide
  5. Suicide

While a cause-of-death diagnosis would reasonably seem to be in the province of someone with pathology training, we now know that at least 20-30 percent of the time the cause was genetic. Thus, trying to determine an MOD for ARD victims is not much different then trying to diagnose a heroin overdose without drug testing. In both cases, the medical examiner is being asked to rule with an incomplete autopsy. For these reasons, many medical examiners are uncomfortable and simply unqualified to make these rulings. However, they are required to by the law in most states.

Darrell Ross has reported on the non-firearm ARD MOD rulings and found that they are indeed fairly arbitrary and random. [4] This is seen in Figure 1.

Figure 1: Non-firearm ARD MOD rulings.
Figure 1: Non-firearm ARD MOD rulings. (Photo/Mark Kroll)

Each and every ruling can be somewhat rationalized:

  1. Natural: The guy had a bad heart from years of drug abuse and it finally gave out with the excitement of being arrested. This could just as well have happened during sex or while climbing the stairs.
  2. Accidental: The guy did not realize that this “recreational” dosage of cocaine or meth would kill him therefore it is an accident (some states have introduced a 6th category of accidental death due to unanticipated consequences of drug use in order to distinguish the cause of death from clear drug overdose)
  3. Homicide: The police touched him therefore it was death “at the hands of another.” (Weird how the paramedics are never criminally charged under similar circumstances.)
  4. Undetermined: There are so many pathological insults going on that we cannot pick out a single MOD. (This is the honest answer.)
  5. Suicide: Rarely ruled in ARDs.

Karch told Police1 that some courts have jumped into this name-game. He brought up a California court ruling where a chronic cocaine user with multiple cardiac abnormalities has a plaque rupture completely occluding a coronary artery, and dies during a dream; you must call it a natural death, even though it was ultimately caused by the chronic cocaine use. On the other hand, if a guy goes to a party, accepts a few lines of cocaine, which leads to a cardiac arrest, it is an accidental death. It was not homicide even though another person was responsible for the death.

Just in case you thought things could not really be this bad, consider the NAME guidelines 16 and 21 for manner-of-death: [5]

16. Deaths due to positional restraint induced by law enforcement personnel or to choke holds or other measures to subdue may be classified as Homicide. In such cases, there may not be intent to kill, but the death results from one or more intentional, volitional, potentially harmful acts directed at the decedent (without consent, of course). Further, there is some value to the homicide classification toward reducing the public perception that a “cover up” is being perpetrated by the death investigation agency.

21. Deaths resulting from grossly negligent medical care (such as inducing anesthesia without resuscitative equipment/supplies available) may be classified as Accident unless there is clear indication of intent to do harm, in which homicide might apply. The criminalization of medical malpractice is of great concern to both the legal and medical professions, and whether or not medical acts of commission or omission meet a legal definition of negligent or other homicide is better left to others more familiar with the legal issues involved.

Note that #16 states that the now-debunked “positional restraint” myth can be used to classify an ARD as homicide! Look at #16 and #21 together and what they are saying: If a police officer’s mistake leads to a death, then we should lean toward homicide for PR reasons. However, we do not want to “criminalize” a fellow physician’s mistake.

Depending on the medical examiner’s office, their feelings toward police, and pressure from local activists and press, the MOD ruling is roughly equally likely to be any of the four main rulings. This would be an amusing academic exercise to discuss except that sometimes the local prosecutor assumes that there is some scientific basis to such a ruling and the police officer is criminally charged. Hopefully, some day we will advance to the British Commonwealth approach of using a Coroner’s Inquest to make the final MOD ruling.          


Don’t automatically assume that a medical examiner’s cause-of-death ruling is accurate. Be especially skeptical if the ruling involves “asphyxia” in some flavor. Understand that the manner-of-death ruling is largely arbitrary when it comes to an arrest-related death. With an ARD, insist that the medical examiner submit blood for full genetic screening and offer to pay for it. If genetic testing has not been done, and the NAME recommendations are followed, police could be wrongfully charged with crimes.

While you are saving up for the mandatory genetic testing, you might want to put some money aside to pay for a cardiac pathology consult as well. Law enforcement agencies should also try to educate their local prosecutors well in advance of an arrest-related death to reduce the risk of a political prosecution.


1. Torkamani A, Muse ED, Spencer EG, et al. Molecular Autopsy for Sudden Unexpected Death. JAMA. 2016;316(14):1492-1494.

2. Karch SB, Brave MA, Kroll MW. On positional asphyxia and death in custody. Med Sci Law. 2016;56(1):74-75.

3. Karch SB. The problem of police-related cardiac arrest. J Forensic Leg Med. 2016;41:36-41.

4. Ross D, Brave M. Assessing TASER® Conducted Energy Weapons, Arrest Related Deaths, and Emerging Liability Trends. Research Gate, #DOI-1013140/RG2229211-26409. 2017.

5. Hanzlick R, Hunsaker J, Davis G. A Guide For Manner of Death Classification. NAME Monograph, 2002.

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