The coronial files of all heroin-related fatalities that occurred in the south western Sydney (SWS) region over the period 1992-1996 were inspected for details and trends in demographic characteristics, circumstances of death and toxicological findings. There were 176 heroin-related fatalities in SWS over the study period. There was a substantial, statistically significant increase in heroin-related fatalities over the study period, from 20 deaths in 1992 to 54 during 1996. The mean age of cases was 29.9 years, 89% were male, and 92% were classified as dependent on heroin at the time of death. Seven percent of cases had recently been released from prison, 2% were enrolled in methadone maintenance at the time of death, and 4% were classified as suicides. There were no significant trends in demographic characteristics of cases over the study period.

Fatalities predominantly occurred in public settings (70%), with Cabramatta being the location in which deaths most frequently occurred (38%). Deaths that occurred in Cabramatta were significantly more likely to have occurred in a public place than other cases (89% v 42%). There was a significant increase over the study period in the proportion of fatalities that occurred in public settings. A third of cases resided outside the SWS region at the time of death. Of those cases in which an estimate could be made, 15% were classified as having died instantly upon heroin administration. No intervention occured in 71% of cases.

Morphine concentrations rose markedly over the study period, from 0.16 mg/L in 1992 to 0.37 mg/L in 1996. The major increase occurred in the period 1992-1994, with morphine concentrations stabilising after this period. The majority of cases involved heroin in combination with other drugs: alcohol (40%), benzodiazepines (30%) and antidepressants (9%). In only a third of cases was morphine the sole drug detected. The median blood alcohol concentration of cases in which alcohol was present was 0.12 g/100 ml. Males were significantly more likely to have alcohol detected at autopsy (44% v 11%), while females were more likely to have benzodiazepines detected (56% v 28%). The median blood morphine concentration among cases in which alcohol was detected was significantly lower than other cases (0.25 mg/L v 0.42 mg/L). In 78% of cases the cause of death was attributed to "acute narcotism" (or "narcotism"). Of the cases in which drugs other than morphine were detected, 69% were attributed solely to narcotism.

The problem of heroin-related fatalities in the SWS region grew throughout the study period. Specific and innovative responses to the problem in this region are necessary if the rise in the number of fatal cases is to be curbed. Possible interventions include educating heroin users on the dangers of the use of other drugs in combination with heroin, the provision of safe injecting rooms to reduce the number of street-based fatalities, expansion of methadone maintenance services in the region, distributing naloxone directly to heroin users, and an improvement of responses to overdoses by witnesses.