S16

S Afr Fam Pract
ISSN 2078-6190    EISSN 2078-6204 

© 2019 The Author(s)

NW REFRESHER COURSE

Unnatural Deaths: are we signing them off as 
“natural” deaths?

Health Professions Amendment Act No 29 of 20071: 

“Death of a person undergoing a procedure of therapeutic, 
diagnostic or palliative nature or of which any aspect of such 
procedure has been a contributory cause, shall not be deemed to 
be a death from natural causes as contemplated in the Inquests 
Act, 1959, or the Births, Marriages and Deaths Registration Act, 
1963”.

Regulation 359 (March 2018) of the National Health Act 
20032: 

These Regulations are called  Regulations  Regarding  the  
Rendering  of Forensic Pathology Service, 2018.

“Unnatural death” for the purposes of the medico-legal 
investigation of death, the following shall be deemed to 
be deaths due to unnatural causes, as contemplated in the 
Inquests Act 1959 (Act No. 58 of 1959):

(a) Any death due to physical or chemical influence, direct or 
indirect, or related complications;

(b) Any death, including those deaths which would normally be 
considered to be a death due to natural causes, which may 
have been the result of an act of commission or omission 
which may be criminal in nature;

(c) Any death as contemplated in section 56 of the Health 
Professions Act, 1974 (Act No. 56 of 1974) See amendment to 
the Act above; and

(d) Any death which is sudden and unexpected, or unexplained, 
or where the cause of death is not apparent.

Unnatural Deaths in Health Establishments2:

1. A person in charge of a health establishment, where a person 
has been declared dead and the cause of death appears to be 
due to unnatural causes must:

(a) Immediately notify the South African Police Service and 
the Service of such death;

(b) Preserve, provide access to and or make available of all the 
relevant medical paraphernalia, exhibits and applicable 
specimens, especially biological fluid specimens in the 
case of suspected toxicology cases;

(c) Ensure access to and availability of all the deceased’s full 

medical records including laboratory and investigative 

reports;

(d) Not hand over the body or items referred to in paragraphs 

(b) and (c) to an undertaker;

2. The medical records and or relevant completed clinical forms 

must accompany the deceased to the designated facility.

The patient using/abusing Anabolic Steroids…..is he/
she at risk for sudden death postoperatively?

An increasing number of young people are taking performing 

enhancing drugs, particularly regular gym attendees and 

recreational body-builders. The commonly used anabolic steroids 

comprise two main groups of drugs: the 17α alkyl derivatives 

taken orally, and the parenteral 17β-ester derivatives.3

These agents may have the following effects, which may impact 

on anaesthesia3:

1. Cardiovascular: 

 ▪ Hypertension 

 ▪ Left ventricular hypertrophy (resulting in diastolic 
dysfunction);

 ▪ Irreversible focal myocardial fibrosis (may act as a focus for 
malignant arrhythmias);

 ▪ Atheromatous coronary artery disease as a result of an 
abnormal lipid profile.

2. Blood components: 

 ▪ Polycythemia

 ▪ Hypercoagulopathy (may result in cerebral thrombosis, 
left ventricular mural thrombus, thrombosis in peripheral 

arteries)

3. Hepatic:

 ▪ Liver dysfunction 

 ▪ Hepatotoxicity

4. Large muscle mass and high caloric intake:

 ▪ May lead to increased oxygen consumption and carbon 
dioxide production.

South African Family Practice 2019; 61(2):S16-S17
 
Open Access article distributed under the terms of the 
Creative Commons License [CC BY-NC-ND 4.0] 
http://creativecommons.org/licenses/by-nc-nd/4.0

Two medicolegal issues of concern
Lundgren AC 

Head of Clinical Governance, Wits Donald Gordon Medical Centre; Honorary visiting Professor, Steve Biko Centre for Bioethics, University of 
the Witwatersrand
Corresponding author, email: chris.lundgren@wits.ac.za



Two medicolegal issues of concern 17

S17

5. Neuropsychiatric effects, which may modify behaviour, as well 
as emergence from anaesthesia.

When assessing these patients preoperatively, it is important 
to check if they are also taking nutritional supplements and 
“accessory” drugs, such as ephedra, insulin, diuretics and growth 
hormone.3

Thus, despite a young body builder being assessed as an ASA 1 
patient, if he/she is using or abusing anabolic steroids and other 
drugs, the anaesthetic may be fraught with problems.

1. No 29 of 2007: Health Professions Amendment Act 2007

2. No R359. No 61 of 2003: National Health Act

3. Kam PCA, Yarrow M. Anabolic steroid abuse. Anaesthesia. 

2005;60:685-92.