Medical Examiner–Assisted Evaluation of Overdose Deaths After Emergency Department Visit

King County, WA continues to experience high rates of overdose death, largely from synthetic opioids. We describe a collaboration between the county medical examiner (KCMEO) and the University of Washington (UW) to link death records with health system data for decedents who visited UW within 30 days before death.

Between Dec 2024–Nov 2025, KCMEO provided monthly death data to UW. Cases with an ED visit ≤30 days before death were analyzed for demographics, visit characteristics, and circumstances of death. Descriptive statistics were calculated; chi-square or Fisher’s exact tests compared categorical variables.

Of 168 decedents, 86 had an ED visit within 30 days prior to death (mean age 46.6 y; mean 7 days to death). Fentanyl was present in 65.1%, methamphetamine in 48.8%; 57% were polysubstance overdoses. Most deaths were accidental (96.5%) and occurred in residences (40.7%), outdoors (19.8%), or hospitals (17.4%). Take-home naloxone was offered/given in 29.1% of ED cases, and MOUD was discussed/prescribed in 9.3%. A chief complaint suggestive of SUD was present in 53.5%; these patients were more likely to receive naloxone vs non-SUD complaints (43.5% vs 12.5%, p=0.0011, OR≈5.4). MOUD offer rates did not significantly differ between SUD and non-SUD complaints (13% vs 5%, p=0.28).

This novel partnership between a medical examiner’s office and a large health system enabled quality improvement review of high-risk ED patients. While SUD-related visits more often resulted in naloxone provision, overall ED rates of naloxone and MOUD offering remain low. Less than 10% of decedents with an ED visit within 30 days of death had a documented discussion about MOUD. These findings indicate an opportunity for quality improvement in care for ED patients with substance use. Further, institution- and context-specific data review can help to identify gaps in care.