“Detection of sedative and antipsychotic in exhumed institutionalized patients: a forensic toxicological case series”

Abstract Post-mortem toxicological analysis in exhumed bodies presents considerable methodological and interpretative difficulties. These limitations become particularly relevant in judicial contexts involving elderly individuals in long-term care, where pharmacological regimens may be deliberately omitted from medical records. This study investigates a series of 15 exhumed cases in which the detection of sedative and antipsychotic drugs, particularly Midazolam and Promazine, raised concerns of potentially unauthorized or inappropriate administration. All cases underwent full forensic autopsy, including external examination and sampling of available biological matrices. Toxicological analyses were performed using GC-MS and LC-MS/MS platforms. Quantitative results were evaluated alongside pathological findings to assess potential contribution to the cause of death. Advanced decomposition affected all cases, severely compromising morphological and histological evaluation. Autopsy findings revealed multiple chronic conditions, consistent with age-related comorbidities. Toxicological screening identified Midazolam, its metabolite α-hydroxy-midazolam, and Promazine in various tissues. However, only one subject had a documented prescription for these agents. In the remaining 14, no therapeutic indication was recorded. All concentrations were interpreted with caution due to decomposition-related artifacts. The interpretation of drug levels in decomposed exhumed bodies is limited by post-mortem redistribution, instability of substances, and the absence of validated reference ranges for degraded matrices. Toxicological positivity, in the absence of medical justification, may support hypotheses of unauthorized administration but cannot by itself establish a causal relationship with death. These findings underscore the need for cautious interpretation and further research on drug behaviour in post-mortem decomposed tissue.