Background: Levomepromazine, a phenothiazine neuroleptic renowned for its sedative effects, plays a vital role in palliative care and psychiatric treatment. This case report sheds light on an unprecedented post-mortem concentration of levomepromazine, surpassing documented levels in existing literature. The primary objective is to heighten awareness and contribute to bolstered patient safety within psychiatric hospital settings.Case Presentation: A man in his thirties, undergoing psychiatric treatment, was discovered unresponsive in his isolated room. Autopsy findings, 36 hours post-mortem, revealed superficial skin depressions resembling window bars on the scalp, neck, and knees, devoid of internal traumatic lesions or underlying pathologies. Postmortem analysis indicated an exceptionally high blood concentration of levomepromazine at
11.059 ng/ml, alongside normal chlorpromazine levels.

The cause of death was identified as a fatal levomepromazine overdose during hospitalization. Investigation into the circumstances facilitating the patient’s access to this medication is ongoing, with details pending. Conclusion: This case highlights the unprecedented elevation of levomepromazine concentration, underscoring the imperative for a thorough investigation into the circumstances leading to such extremes. While the drug is indispensable in psychiatric care, its potential for toxicity emphasizes the need for meticulous prescribing, vigilant monitoring, and patient education.

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