Understand the Culture in Which You Practise Hyperthermia: Are ...

coroner’s report
Coroner’s Inquest into death
due to Hyperthermia
D.B. was a 36 year old man with a medical history of Schizophrenia
and was on Benztropine, Quetiaine, Zuclopenthixol
and Carbamazepine. He had been on these medications at
the same dose since August 2002.
He was a roofer, part of a crew replacing a roof on a canning
plant on May 29, 2006. It was the first hot and humid
day of the year. The humidex that day during work hours
ranged from 34 to 43 degrees C. Members of the crew felt
ill and were taking frequent breaks and drinking significant
amounts of water. Some time in the afternoon, D.B. was
noted to be staggering and unsteady on his feet. He rested
in the shade for 1 hour, and after that, was not answering
appropriately and was ordered off the roof to rest for the
rest of the day. D.B. changed his clothes, and was observed
to be sitting in the truck, then staggering and stumbling outside
the truck. He fell to the ground and a co-worker came
off the roof and called 911. He was unresponsive and was
transported to hospital where his core temperature was
42.2 C. Despite aggressive medical efforts, D.B. continued
to deteriorate and was pronounced dead the next morning.
The coroner’s jury made three recommendations to the
Ministry of Labour regarding policies for heat stress, and
first aid training for heat stress. As well, three recommendations
were made to the Ontario College of Pharmacists
as follows:
Recommendation 4
The pharmacist will review annually the side effects of
medication with the patient.
Coroner’s Comments
The jury heard evidence that the pharmacist discusses information
about prescription drugs with the patient when
the medication is first prescribed, when there are any
changes in dose or dosing frequency, or if the patient has
any problems or concerns. The pharmacist does not generally
review the medication side effects etc. on medication
renewals. The jury felt there should be regular reviews of
the medication side effects between the patient and the
pharmacist.
Recommendation 5
Provide a warning label on any medication that inhibits the
body from temperature regulation.
Coroner’s Comments
The jury heard evidence that the information given in the
drug information sheets does not specifically mention heat
related side effects of heat stroke. There are stickers that
are attached to pill bottles for certain potential hazards such
as “may cause drowsiness” or “not to be taken with alcohol”.
The jury felt that developing a sticker to be placed
on the prescription pill bottle regarding the drug’s effect on
temperature regulation would serve as a daily reminder to
the patient of this potential serious effect.
Recommendation 6
Introduce a method of patient notification of any change
to a drug’s characteristics or profile that may impact the
patient’s health.
Coroner’s Comments
The jury heard evidence that the drug information database
is constantly updated and that new information is incorporated
in the drug information sheets that are given to
the patient. However, if changes have occurred in the information
after the patient receives the information sheets,
continued on page 36
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