An analysis of factors contributing to a series of deaths caused by exposure to high environmental temperatures

Autopsy reports at the Forensic Science Centre, Adelaide, South Australia, were reviewed for the 8 years from January 1991 to December 1998 for cases with unusual features in which deaths had been attributed to exposure to high environmental temperatures. Amphetamine-related hyperpyrexial deaths, anesthetic deaths caused by malignant hyperpyrexia, deaths of elderly incapacitated individuals during heat waves, and deaths of children trapped in the back of cars were excluded from the study. In 9 cases, where heat-related deaths had occurred (age range 21 to 77 years; M:F = 8:1). Predisposing factors included lack of familiarity with Australian environmental conditions, excessive clothing, prolonged sun exposure, acute alcohol intoxication, obesity, benztropine and trifluoperazine medication, and underlying dementia, alcoholic liver disease, and possibly epilepsy.     

The descriptive epidemiology of unnatural deaths in Oregon's state institutions: a 25-year (1963-1987) study. III. A 25-year overview of unnatural deaths in the mental and correctional facilities.

I document 25 consecutive years (1963-1987) of unnatural deaths within the State of Oregon's mental and correctional institutions in Marion County. This study includes 93 unnatural deaths in the Oregon State Hospital, 18 in the Forensic Psychiatric Program, 52 in the Fairview Training Center, and 45 in the Corrections Department facilities. These institutional unnatural deaths are compared with the 2,618 unnatural deaths that occurred during this same period in Marion County (exclusive of these state facilities). Death rates are shown in five 5-year blocks of time to illustrate death trends. Accidents and suicides were the predominant types of unnatural death in the Oregon State Hospital; suicides predominated in the Forensic Psychiatric Program and the corrections facilities; and accidents predominated in the Fairview Training Center. Extremely high total unnatural death rates were found in the Oregon State Hospital (approximately 520/100,000 or 8.46 times that found in Marion County) and the Forensic Psychiatric Program (approximately 561/100,000 or 9.13 times that found in Marion County). The overall accident death rate for the Fairview Training Center was approximately 119/100,000 or 2.84 times that found in Marion County. The overall total unnatural death rate for the corrections facilities was approximately 75/100,000 or 1.23 times that found in Marion County. I compare these data with those of other investigators in the United States, Canada, and western Europe. The total unnatural death rate appears to represent a valid criterion of violent death within a community.     

An Analysis of The Morbidity and Mortality of Diabetes Mellitus in a Forensic Context

To investigate the spectrum of diseases seen in diabetes mellitus in a forensic context, all autopsy reports of diabetic individuals who presented to Forensic Science, South Australia (FSSA), over a 5‐year period from 2005 to 2009 were studied. The leading cause of death was cardiovascular disease (55.0%), followed by unnatural deaths (15.4%) and infections (9.4%). In type 1 diabetics, principal causes of death included cardiovascular disease (44.7%), acute metabolic complications (18.7%), unnatural deaths (17.9%), and infections (8.9%). However, frequencies of these diseases differed in type 2 diabetics, with cardiovascular events responsible for 56.6% of cases, followed by unnatural deaths (15.0%) and infections (10.9%). A larger number of male deaths were seen in all disease categories, except respiratory and gastrointestinal where the frequencies were similar to females. Cardiovascular disease was the leading overall cause of death across all ages except in those under the age of 30 where metabolic complications were more common.     

Hypothermia: autopsy findings and vitreous glucose

Anatomic lesions associated with hypothermia are variable and nonspecific. Only a few gross lesions and no microscopic pathology were noted in the acute deaths of this series. An interesting anatomic observation was the low weight of the lungs in 45% of the hypothermic deaths. Hypothermia is recognized as frequently producing hyperglycemia and 80% of a group of such patients clinically treated at the Hennepin County Medical Center had elevated blood sugar values. This correlates with an average vitreous glucose of 82.6 mg/dL in the hypothermic deaths. By contrast, the average vitreous glucose value found in each of two separate control groups was 37 mg/dL. Establishing hypothermia as the cause of death requires a proper history of exposure and the absence of any other clear-cut lethal factor. Certain biochemical tests may provide supporting evidence. Among these is an elevated vitreous glucose in a nondiabetic individual.     

Pregnancy-associated deaths: a 15-year retrospective study and overall review of maternal pathophysiology

Pregnancy-related death is defined by the International Classification of Diseases, Tenth Revision (ICD-10) as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death. In the year 2000, a collaborative effort involving World Health Organization (WHO), UNICEF, and UNFPA estimated 660 maternal deaths in the United States. This averages 11 maternal deaths per 100,000 live births reported. Many pregnancy-associated deaths are not easily identified as such since the presence of a recent or current pregnancy may not be listed on the death certificate. Thus, the WHO estimates that in the United States, the maternal mortality is approximately 17/100,000 pregnancies. This is significantly higher than the goal set by the US Department of Health and Human Services in Healthy People 2010, which sets the target for maternal mortality at less than 3.3/100,000 live births. The most common causes of maternal death vary somewhat from region to region in the United States. They include pulmonary thromboembolism, amniotic fluid embolism, primary postpartum uterine hemorrhage, infection, and complications of hypertension including preeclampsia and eclampsia. Pulmonary disease, complications of anesthesia, and cardiomyopathy also are significant contributors to maternal mortality in some populations. The death of a pregnant or recently pregnant individual poses a wide scope of challenges to the forensic pathologist and investigator. The pathologist must have a broad knowledge of the physiologic and biochemical changes that occur during pregnancy, as well as the clinical and pathological manifestation of these changes. Conditions that may be "benign" in the nonpregnant individual may be lethal in the puerperal period. In addition, it should be kept in mind that deaths during pregnancy may be due to unnatural causes. Accident, homicide, and suicide must be ruled out in each case. The authors reviewed all forensic cases referred for autopsy to the Forensic Section of the Medical University of South Carolina from January 1989 through December 2003. All decedents listed as pregnant or postpartum were analyzed as to maternal age, race, past medical history, previous pregnancies and outcome, prenatal care, gestational age, fetal or neonatal outcome, location of delivery, placental findings, maternal autopsy findings, toxicology, cause of death, manner of death, and fetal or neonatal autopsy findings. The authors present this retrospective study to better determine the factors leading to maternal demise and discuss the autopsy/ancillary techniques useful in determining the cause of death in this challenging area.     

Forensic Features of Lethal Late‐Presenting Diaphragmatic Hernias

Diaphragmatic defects are a relatively common and benign finding in adults which may be congenital or secondarily acquired. The case files at Forensic Sciences South Australia were reviewed over a 10‐year period from July 2005 to June 2015 for all adult (>17 years) cases in which diaphragmatic hernias were identified at postmortem examination that had either caused or contributed to death. Five cases were found: age range 49–90 years (average 67.2 years); male:female ratio 2:3. Herniated organs included the stomach (N = 3), small (N = 3) and large intestines (N = 2). Mechanisms of death involved lung compression with respiratory failure and/or mediastinal shift, and vascular compromise with gastric or intestinal infarction and/or perforation. Diaphragmatic hernias may not be identified until the time of autopsy and may be quite complex entities to evaluate due to a lack of clinical history and to difficulties in determining their origin and possible contributions to mechanisms of death.     

Carbon monoxide-related deaths in a metropolitan county in the USA: an 11-year study

Carbon monoxide (CO) poisoning as a cause of death is well documented in industrialized countries. The objective of this study was to compare demographic data in deaths due to accidents (in fires) and suicides in the same population between 1988 and 1998. Furthermore, the potential effect of a community wide education effort regarding safety in the home was assessed. Postmortem reports were reviewed for all deaths examined at the Office of the Cuyahoga County Coroner in Cleveland, OH, USA. During the study period, there were 209 accidental deaths due to fires in the home (6.5% of all accidents in the home) and 182 CO deaths by suicide (9.8% of all suicides). Demographic characteristics of the two groups differed: while males represented the majority of cases in both groups (55% of accidents, 70% suicides), race specific death rates were higher for whites than blacks (18/100,000 white, 3/100,000 black) in suicides compared with 29/100,000 deaths for blacks and 11/100,000 for whites in accidental cases. Fire deaths were prevalent in the young (0-9 years) and old (>60) whereas in the suicide group the age specific death rate was highest for those over 70 years. The majority of fire deaths occurred in the city of Cleveland but suicides were prevalent in the suburbs. More fire deaths occurred in December than any other month whereas more suicides occurred in April. In 1992, there was a community wide effort to provide free smoke detectors to residents in Cleveland. In 1992, there were 4.2/100,000 fire deaths in the city. This decreased to 0.6/100,000 in 1996, increased to 1.2/100,000 in 1997 followed by a decrease to 0.8/100,000 in 1998. This suggested that the program may have aided in decreasing these types of deaths. Deaths due to fires in the suburbs were <1/100,000 throughout the study period.     

Inhalant deaths in South Australia: a 20-year retrospective autopsy study

A 20-year retrospective study of inhalant deaths in South Australia, autopsied at Forensic Science SA, was undertaken from January 1983 to December 2002. Thirty-nine cases were identified from an autopsy pool of 18,880 cases, with a male to female ratio of 12:1. Sixty-four percent of the victims (N = 25) died during voluntary inhalation of volatile substances and 28% (N = 11) committed suicide utilizing a volatile substance or gas. The remaining 3 cases involved a workplace accident (N = 1) and 2 cases of autoerotic death where inhalants were being used to augment solitary sexual activity. The mean age of the 28 victims of accidental inhalant death of 21 years (range, 13-45 years) was considerably less than that of the 11 suicide victims of 31.5 years (range, 17-48 years). No homicides were found. Approximately one quarter of the victims were Aboriginal (N = 11), 10 of whom had died as a result of gasoline inhalation ("petrol sniffing"). Other common substances of abuse were aliphatic hydrocarbons such as butane. The study has shown that those most at risk for accidental or suicidal inhalant deaths were young males, with 92% of victims overall being male, and with 77% of victims being under 31 years of age. Gasoline inhalation remains a significant problem in Aboriginal communities in South Australia.     

Flail Chest Following Failed Cardiopulmonary Resuscitation

Following the death of a woman with blunt force chest trauma, the question was asked how common was the finding at autopsy of a flail chest in decedents after failed cardiopulmonary resuscitation. It was suggested in court that this was an uncommon occurrence. To address this issue, autopsy cases in adults (>18 years) with rib fractures attributable to cardiopulmonary resuscitation were taken from the files of Forensic Science SA over a 7‐year period from 2008 to 2014. Flail chest injuries were defined as those arising from fractures at two sites in at least three consecutive ribs. From 236 cases with rib fractures attributed to resuscitation, a total of 43 flail chest injuries were found in 35 cases (14.8%). The majority occurred in the 60‐79‐year‐old age group. These data suggest that flail chest injuries are a more common sequelae of cardiopulmonary resuscitation than has been previously appreciated in autopsy cases, particularly in the elderly.     

Recent Firing Range Suicides in South Australia

Abstract: Two cases are reported from South Australia, where deaths occurred that were due to single self‐inflicted gunshot wounds to the head in individuals who were visiting indoor firearm ranges. Case 1: A 54‐year‐old man visiting an indoor firing range placed a .357 magnum handgun to his head and fired one shot. Case 2: A 23‐year‐old woman who was being instructed in firearm usage at an indoor firing range placed a 9 mm handgun to her head and fired one shot. In both cases, deaths were due to cerebral laceration with skull fracture. Firing ranges may be utilized by individuals who are seeking weapons for suicide attempts, and suicide may be successfully undertaken at such locations even while a victim is under direct supervision. In jurisdictions, where firearm ownership is strictly legislated, it may be that clubs can inadvertently provide access to firearms for this type of activity.     

Trends in firearm-related deaths in the Transkei region of South Africa

BACKGROUND: Firearms tends to be seen today as instrumental in injuries and deaths, including suicide. South Africa's gun law allows firearms to be licensed and legal, so in general they are not illegal weapons, even though many used in violence are illegal. This is a prime area in which multisectorial collaboration is needed in a country like South Africa. OBJECTIVE: The purpose of this study is to determine the incidence of firearm-related deaths and to understand the underlying causative factors. METHOD: This is a record review of 10,860 medicolegal autopsies conducted between 1993 and 2004 at Umtata General Hospital. RESULTS: Between 1993 and 2004, there were 10,860 autopsies performed of those who died as a result of trauma and others in Umtata General Hospital. The average gunshot-related deaths during this period are 48.4 per 100,000 of the population per year. The rate has increased from 27 per 100,000 in 1993 to 42 per 100,000 in 2004. It was climbed to its peak to 67.8 per 100,000 in 2001. Firearm-related deaths account for 29% of all traumatic deaths. Males (82%) outnumber females 4.6:1 in fatalities due to firearms. There is an increasing trend in females. About 50% were in the 21- to 40-year age group. Interpersonal violence, poverty, and use of drugs and alcohol are common underlying factors. CONCLUSION: There is a high incidence of firearm-related deaths in Transkei, which is in support of stricter gun control.     

Discrepancies in Death Certificates,Public Health Registries,and Judicial Determinations in Italy

The death certificate is mandated by civil law and serves as a medical‐scientific document useful for biostatistics and epidemiological research. For a variety of reasons, death certificates can be misclassified. We reviewed data from self‐inflicted deaths collected over an 8‐year period by the Forensic Institute of the University Sacro Cuore of Rome (Italy). Four hundred and thirty‐five of 2904 were classified as self‐inflicted deaths (15%). The comparison with death certificates processed by the local public health authority (ASL) and by the Italian National Census Bureau (Istat) and with the judicial investigation results available in the Italian Penal Court archive shows some discrepancies. One‐hundred and twenty‐four of 435 deaths were not considered to be self‐inflicted but due to a crime (29% overrecording suicide) with a higher reduction for women, suggesting that it is easier to confuse a murder for suicide in female cases. Any discrepancies between the mortality and crime data are discussed in details.     

Wandering Dementia—A Syndrome with Forensic Implications

Wandering behavior in dementia may result in significant injury or death. Search of files at Forensic Science South Australia over a 20‐year period (1998–2018) identified nine individuals with dementia who were found deceased having been reported as missing from home/residential facilities (M:F, 6:3; age range, 54–92 years; average, 77.7 years; median, 80 years). The established clinical diagnoses were of dementia in seven cases and Alzheimer disease in two. Deaths were unnatural in six cases: hypo/hyperthermia three, drowning two, train impact one; natural in two cases due to ischemic (N=1) and valvular heart disease (N=1); and undetermined in one case due to marked decomposition. There were five fatalities in winter. Exposure and drowning were significant causes of death. The increasing aging population means cases of lethal wandering dementia will be more often encountered among forensic cases in future. Issues around duty of care and suicide should be considered in evaluating cases.     

Hypothermia-related Deaths: A 10-year Retrospective Study of Two Major Metropolitan Cities in the United States*

Hypothermia-related deaths affect vulnerable populations and are preventable. They account for the vast majority of weather-related deaths in the United States. The postmortem diagnosis of hypothermia can be challenging, as there are no pathognomonic signs. The electronic databases of the New York City Office of Chief Medical Examiner and Harris County Institute of Forensic Sciences were searched for all fatalities where the primary cause of death included hypothermia, between January 2009 and July 2019. There were 139 hypothermia deaths in New York City (NYC) with an average annualized rate of 1.7 per million. During this same time, there were 50 hypothermia deaths in Houston with an average annualized rate of 2.4 per million. Males were more likely to die of hypothermia compared to females in both cities. The rate ratio (RR) in NYC was 3.55 (95% CI 2.40, 5.25), while the RR in Houston was 2.83 (95% CI 1.50, 5.32). Age- and sex-specific standardized hypothermia mortality rates were 18.2 (95% CI 15.1, 21.2) per million in NYC and 30.1 (95% CI 21.7, 38.6) per million in Houston. The comparative hypothermia death ratio was 1.66 (95% CI 1.19, 2.30), indicating hypothermia mortality in Houston was 66% higher than in NYC. There was no correlation between zip code poverty rates and hypothermia-related deaths. The most consistent autopsy finding was Wischnewski spots (56.6%), and ethanol was the most common toxicological finding (36.5%). Local agencies can use this data to target these higher-risk populations and offer appropriate interventions to try to prevent these deaths.     

32例妊娠期死亡法医病理学研究

目的　探讨妊娠死亡的特点。　方法　对 1990～ 2 0 0 0年间华西医科大学法医学院所做 3 2例妊娠死亡尸检病例进行分析。　结果　妊娠产妇死亡年龄以 2 5～ 3 0岁为多见 ,职业以农民常见 ,且绝大多数无产前检查记录 ,死亡多发生于分娩过程中 ,区、乡一级卫生院多发。前四位的死因依次为 :胎盘残留、输卵管妊娠破裂、产后感染和子宫血管结扎出血 ,绝大多数妊娠产妇死亡前产下活婴。　结论　有必要加强基层与农村医疗保健工作和制订有关的预防措施 ,以降低妊娠产妇的死亡率。     

Recent trends in suicides utilizing helium

Retrospective review of cases of suicide involving helium inhalation was undertaken at Forensic Science South Australia over a 25-year period from 1985 to 2009. No cases of helium-related suicides were identified in the first 15 years of the study, with one case between 2000 and 2004 and eight cases between 2005 and 2009. Australian data were also reviewed from 2001 to 2009 that showed 30 cases between January 2001 and June 2005, compared to 79 cases between July 2005 and December 2009, an increase of 163%. A review of Swedish data between 2001 and 2009 showed no cases between January 2001 and June 2005, compared to seven cases between July 2005 and December 2009. Thus, all three areas showed recent and striking increases in cases of suicide involving helium inhalation. Given the availability of helium and the recent promotion of this method of suicide, it is quite possible that this may represent a newly emerging trend in suicide deaths.     

Cluster hanging suicides in the young in South Australia

Retrospective review of hanging suicides in individuals aged ≤ 17 years was undertaken at Forensic Science South Australia, Australia, over two 5-year periods: 1995-1999 and 2005-2009. Seven cases of hanging suicides were identified from 1995 to 1999, with a further 14 cases from 2005 to 2009, an increase of 100% (p < 0.001). Hanging accounted for 33.3% of all suicides in this age group (7/21) from 1995 to 1999, compared with 93.3% of the total number of suicides (14/15) in the second 5-year period. In contrast, Australian national data from 1998 and 2008 showed a 30% decrease in hanging suicides in the young, from one case/100,000 population in 1998 to 0.7 in 2008. Cluster suicides occur in the young and are often initiated by direct communication. As it is possible that Internet-based social sites may facilitate this phenomenon, investigations should include an evaluation of the victim's Internet access given the potential risk of similar actions by peers.     

Increasing Methamphetamine Detection in Cases of Early Childhood Fatalities

Age and organ maturity can influence drug toxicity in children; however, most clinical data and literature are based on drug concentrations in adults. Therefore, the interpretation of drugs detected in children is often difficult or not possible. Retrospective reviewing of pathology and toxicology information from postmortem cases may assist in future interpretations or identify drug trends. A search of the Forensic Science SA case files was undertaken over 15 years from January 2002 to December 2016 for all children (<13 years). Of the 412 pediatric coronial cases, toxicological information was available on 373. At least one drug was detected in 94 cases with paracetamol, ibuprofen, codeine and hospital-administrated lignocaine and morphine among the most commonly detected agents. Methamphetamine, one of the most commonly abused illicit drugs in Australia, was found in seven cases. In the methamphetamine cases, deaths were associated with shared sleeping in three, pneumonia in one, and stillbirth in one. Methamphetamine was considered potentially contributory to death in two cases. The causes of death in the remaining two cases were undetermined. As six of the seven positive cases occurred in the 2012–2016 (n = 106) timeframe, an increase has occurred over recent years in the number of infants and young children presenting to forensic autopsy in South Australia who have detectable concentrations of methamphetamine. If this is an indication of a more generalized increased childhood exposure in the community there may be significant long-term physical and psychological effects.