Emergency Casebook 4: It’s Cold Outside


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Author: Susie Hewitt / Codes: CC1, CC6, HAP11, EnvC3, MHC1, MHP4, MHP5, SLO1, SLO12, SLO7 / Published: 23/12/2015

This is the fourth in a series of Emergency Casebooks from the virtual hospital CFN General, with key learning points for staff working in an Emergency Department

Source: Inquest

Case summary

In January 2011 the police were called to a house in Cemville. A GP had gone to the house to check on a patient and found the body of a male in the garden. The GP recognised the man as his patient, Mr D. The body was only partially clothed and covered with multiple bruises and abrasions. Clothing, including a coat, was found by the back door. Empty bottles of alcohol were found nearby. The house was locked and there was no key in Mr D’s clothing or at the scene. During the night a neighbour recalled hearing loud banging. The police secured the area as a potential crime scene.

Initial investigations revealed that Mr D had been to the ED in the early hours the same day. This was his third attendance to CFN General Emergency Department (ED) that month. He had a long history of alcohol problems and a recent history of self-harm. He had been charged with drink driving a few weeks before this, his family had fallen out with him and he felt he could not cope. He had recently started antidepressants.

On the first attendance to ED he was intoxicated and had evidence of recent self-harm to his wrists. The doctor recognised his vulnerability and risk factors but Mr D did not want to stay in ED as he wanted to be able to get to work the following morning. He absconded while the doctor was taking advice. A detailed letter was sent electronically to his GP.

A few days later he attended ED again. He had been arrested by the police for being drunk and disorderly. He stated he had taken an overdose but later denied this stating he had only taken one temazepam tablet. Examination was normal and he required no treatment. Paracetamol and salicylate were not detected. He was discharged in the care of the police with a plan for a mental health assessment to take place in custody.

On the day before Mr D was found dead he had seen his GP. The GP planned to make telephone contact with him later that afternoon but was unable to find him. The GP became concerned and an ECP attended Mr D’s home and found him to be intoxicated. After intravenous fluids Mr D was said to have improved. On arrival in ED his observations were normal. Mr D denied current suicidal thoughts or overdose. Clinical examination was normal. The computerised records show that Mr D left the department at 03.30 however it was not possible to determine from the note whether he had been formally discharged or has absconded.

A post mortem examination concluded that Mr D had died from hypothermia. During the Trust review into Mr C’s care in the ED a member of staff recalled that he had his house key tied to a bandage which he was wearing around his neck.



  • Hypothermia occurs most often among people who abuse drugs or alcohol, the chronically ill, very old or very young people, and those who are malnourished.
  • As hypothermia progresses, most victims will have movement problems, such as stumbling, slowing down and poor coordination. They may also appear dazed, disoriented or confused, with slurred speech or act as if under the influence of drugs or alcohol.
  • If hypothermia becomes severe, respiration and heart rates slow, the victim will lose consciousness and may eventually die. Before losing consciousness, people suffering from hypothermia have been known to exhibit bizarre behaviours including “paradoxical undressing” and “terminal burrowing”.
  • Some victims of extreme hypothermia take off most or all their clothing. Usually the cold produces profound vasoconstriction in the skin to reduce heat loss but over time the muscles responsible for vasoconstriction become exhausted and warmer blood enters the extremities causing a “hot flash.” The confused and disorientated victim feels they are burning up so they remove their clothes.
  • Paradoxical undressing often occurs immediately before terminal burrowing. This behaviour is not well understood but appears to be a primitive response similar to animals that hibernate in tight surroundings to help to minimise heat loss. Victims who are found dead from hypothermia are often discovered under a bed or behind a wardrobe as a final mechanism of protection.
  • Because of terminal burrowing and paradoxical undressing, victims of hypothermia can be mistaken as victims of crime such as sexual assault and their discovery inside a small, enclosed space, such as beneath furniture,  may look like an attempt to hide the body.

General learning

  • In this case Mr D’s coat had been found at the scene and he had his key when he left the ED, however during this winter think about patients who are discharged, and especially those who abscond, and consider whether they are appropriately dressed for the conditions and if they are at risk.


The coroner reached a conclusion of accidental death caused by hypothermia exacerbated by excess alcohol consumption. The coroner made a finding of fact that Mr D had his key when he left the ED and that he had consumed more alcohol after leaving ED prior to his death. The coroner concluded that the care in the ED and by his GP was appropriate.

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