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Various toxicities: case report A woman in her 30s [exact age not stated] died due to drowning under the influence of aripiprazole, flunitrazepam, quetiapine and escitalopram. It was suspected that the risk of drowning was increased as she might have impaired psychomotor performance, somnolence and prolongation of QT interval due to the pharmacodynamic interaction between escitalopram and quetiapine [dosages not stated]. The woman was found dead in her bathtub. She had been prescribed several drugs (aripiprazole, flunitrazepam, quetiapine and escitalopram) for the treatment of depression or insomnia, as reported in a post-mortem investigation by the authorities. Autopsy findings indicated no evidence of external injuries. Her heart weighed 282g and contained 75mL of blood with a small amount of coagulum. Her brain weighed 1248g and was slightly oedematous. Her left and right lungs weighed 439g and 379g, respectively, and were slightly oedematous. The stomach contained 200mL of a greenish-brown muddy liquid. Internal examination revealed no diseases. Except for congestion, there were no notable changes in the other organs. Post-mortem blood, CSF, bile and stomach content samples were collected for toxicological investigation. However, a urine sample was not available. Quantification of ethanol was performed using headspace gas chromatography; however, ethanol was not detected in her post-mortem samples. Toxicological analysis of the prescribed drugs (aripiprazole, flunitrazepam, quetiapine and escitalopram) were performed using liquid chromatography tandem mass spectrometry (LC-MS/MS). Quantitative toxicological analysis of femoral blood sample revealed concentrations of quetiapine, escitalopram, aripiprazole and 7-aminoflunitrazepam (a metabolite of flunitrazepam) of 1.266 µg/mL, 0.609 µg/mL, 0.124 µg/mL and 0.055 µg/mL, respectively. Quantitative toxicological analysis of CSF revealed concentrations of aripiprazole, escitalopram, flunitrazepam, 7-aminoflunitrazepam (a metabolite of flunitrazepam) and quetiapine of 0.013 µg/mL, 0.219 µg/mL, 0.001 µg/mL, 0.028 µg/mL and 0.222 µg/mL, respectively. Quantitative toxicological analysis of stomach content revealed concentrations of aripiprazole, escitalopram, flunitrazepam, 7-aminoflunitrazepam (a metabolite of flunitrazepam) and quetiapine of 0.296 µg/mL, 1.111 µg/mL, 5.418 µg/mL, 4.202 µg/mL and 1252.892 µg/mL, respectively. Quantitative toxicological analysis of bile revealed concentrations of aripiprazole, escitalopram, 7-aminoflunitrazepam (a metabolite of flunitrazepam) and quetiapine of 0.860 µg/mL, 4.714 µg/mL, 5.418 µg/mL, 0.479 µg/mL and 23.588 µg/mL, respectively. It was concluded that the concentration of each drug in bile was higher than that in blood, and the drug concentrations in CSF were lower than those in blood. Post-mortem blood concentrations of quetiapine and escitalopram were over the therapeutic range and within the toxic range. Since both quetiapine and escitalopram have H1 receptor antagonistic actions, the two drugs might have enhanced so