By Justin M. Feldman, Tracey Lloyd , Phillip Atiba Solomon

 Background: Mortality classification for deaths in US police custody has important consequences for epidemiologic monitoring and legal outcomes. Prior literature suggests in custody death classification is inconsistent and may not reflect non-firearm force that preceded death. Methods: We analyzed the Associated Press “Lethal Restraint” national dataset (United States, 2012-2021; N = 1,036), which included deaths following police use of non-firearm force. Our primary outcomes included whether the death investigator: (1) classified manner of death as a homicide, (2) mentioned a force-related injury/condition in the cause-of-death statement, and (3) mentioned any force. Inverse-probability-weighted logistic models estimated the association of these outcomes with death-investigator jurisdiction type, local political composition (quartile of Republican Party vote %), decedent race/ethnicity, and each agency’s prior classifications. Findings: We removed 96 deaths based on exclusion criteria. Of the remaining 940 deaths, 28.5% were classified as homicide, 16.5% had cause-of-death statements mentioning a force-related injury/condition, and 42.6% mentioned any force. In contrast, 73.9% of statements mentioned drugs. Unadjusted results showed homicide classification increased from 25.0% in 2012-2014 to 32.2% in 2018-2021. Models estimating adjusted prevalence differences (aPD) showed that, compared to medical examiner jurisdictions, coroners (aPD: -0.19; 95% CI: -0.31, - 0.06) and sheriff-coroners (a PD: -0.17; 95% CI: -0.28, -0.05) were less likely to classify deaths as homicides. Model results also showed that classifications for incidents occurring in the leastRepublican counties were most likely to reflect force across all three manner and cause outcomes. Interpretation: Non-homicide classifications and cause-of-death statements making no mention of force were widespread for US in-custody deaths. We identified novel evidence suggesting coroner and sheriff-coroner jurisdictions were especially unlikely to categorize in-custody deaths as homicides, and that incidents occurring in highly Republican counties were least likely to reflect force in the cause or manner of death. 

By Victor Weedn , Alon Steinberg , Pete Speth 

We postulate that most atraumatic deaths during police restraint of subjects in the prone position are due to prone restraint cardiac arrest (PRCA), rather than from restraint asphyxia or a stress‐induced cardiac condition, such as excited delirium. The prone position restricts ventilation and diminishes pulmonary perfusion. In the setting of a police encounter, metabolic demand will be high from anxiety, stress, excitement, physical struggle, and/or stimulant drugs, leading to metabolic acidosis and requiring significant hyperventilation. Although oxygen levels may be maintained, prolonged restraint in the prone position may result in an inability to adequately blow off CO2, causing blood pCO2 levels to rise rapidly. The uncompensated metabolic acidosis (low pH) will eventually result in loss of myocyte contractility. The initial electrocardiogram rhythm will generally be either pulseless electrical activity (PEA) or asystole, indicating a noncardiac etiology, more consistent with PRCA and inconsistent with a primary role of any underlying cardiac pathology or stress‐induced cardiac etiology. We point to two animal models: in one model rats unable to breathe deeply due to an external restraint die when their metabolic demand is increased, and in the other model, pressure on the chest of rats results in decreased venous return and cardiac arrest rather than death from asphyxia. We present two cases of subjects restrained in the prone position who went into cardiac arrest and had low pHs and initial PEA cardiac rhythms. Our cases demonstrate the danger of prone restraint and serve as examples of PRCA.

By Emmert Roberts, Sharmila Parmanand, Caroline Copeland

Individuals engaged in sex work are an understudied population recognised to be at differential risk of experiencing drug-related harms. We aimed to determine the case characteristics, circumstances of death and type of implicated drugs among sex workers dying due to drug-related causes.

Methods

Retrospective cohort study in the United Kingdom using coronial records from the National Programme on Substance Use Mortality, 1997–2023. Information was available on decedent sociodemographics, characteristics of death and implicated drugs.

Results

Nineteen decedents were reported to be sex workers at the time of their death. Overall, decedents were predominantly female (n = 17, 90%) with a mean age of 36.4 years (SD 8.0; range 26–58). Poisoning was the only disease or condition that was certified as a direct, antecedent or contributory cause of death. The mean number of drugs detected at post-mortem was 5.4 (SD 2.5; range 1–10) with multiple drug toxicity implicated in the majority of cases (n = 18, 95%). The most commonly implicated drug groups were opioids (n = 17, 90%) and benzodiazepines (n = 9, 47%). All decedents had a history of substance dependence (n = 19, 100%), with almost a third injecting (n = 6, 32%).

Discussion and Conclusions

There have been low but consistent numbers of drug-related deaths each year where individuals were reported to be sex workers, results likely representing significantly conservative estimates. Polysubstance, opioid and benzodiazepine use are overrepresented within a largely female population with a significant burden of substance dependence. Non-judgmental facilitation of access to evidence-based addiction treatment, in particular for opioid use disorder, should be a priority.

Summary

• International research consistently reports an increased risk of drug-related harm among individuals who are engaged in sex work.

• Over the last two decades in the UK, there have been 19 drug-related deaths where individuals were reported to be sex workers.

• Overall decedents were predominantly female and all had a history of substance dependence. Opioids were implicated in death in the majority of cases.

• Non-judgmental facilitation of access to evidence-based addiction treatment, in particular for opioid use disorder, should be a priority.

• There are likely a substantial number of individuals engaged in sex work where this had either not been established by those submitting coronial evidence, or their sex work status was not deemed pertinent to report. As such, numbers reported are likely to represent significantly conservative estimates.

Drug and Alcohol Review, July 2025