Fatal injuries are an important part of medicolegal practice and include injury sustained in a road traffic collision, fall, blunt/sharp force trauma, firearm injury, asphyxia, poisoning and other external violence. Injuries continue to be a significant public health problem at the global level, especially in the economically productive and youth population. Road traffic injuries are responsible for around 1.16 million fatalities per year, most of which take place in low and middle-income countries [1,2].

In Pakistan, road traffic accidents are a significant proportion of unnatural deaths that are medicolegally investigated; autopsies have shown that there is a significant variation in demographics of victims as well as their injuries and the anatomical causes of death [3]. Suicide and homicide make up a significant proportion of fatal injury mortality as well and the World Health Organisation estimates over 720,000 suicide-related deaths per year globally [4]. These various mechanisms result in characteristic, but frequently overlapping patterns of injury, which are best assessed forensically in a systematic manner.

Fatal injuries are defined and interpreted based on the nature, number, anatomical distribution, severity, likely mechanism of injury and demographic and clinical characteristics. Blunt trauma often results in mortal injuries with involvement of multiple body areas including the head, chest and abdomen, and penetrating and sharp force trauma can show characteristic wound patterns which can help to differentiate homicide and suicide [5,6]. Likewise, when investigating firearm-related deaths, the location of the wound, trajectory, range of fire, associated injuries, and toxicologic results are all important to evaluate in determining the manner of death [7]. In Pakistan, studies on autopsy of road traffic accident (RTA) deaths have pointed out head injury and multiple traumatic injuries are the common causes of death, with the fractures involving the skull and thoracic area being common [3].

 A thorough analysis of the pattern of injuries is therefore crucial in determining the cause and manner of death and is also able to be correlated with the circumstances surrounding the fatal event.

Medicolegal examination of death is not limited to autopsy results, and all of the facts and circumstances, including the scene, clinical records, post mortem, histopathology and forensic toxicology, need to be considered. The reliability of cause and manner of death determination relies on the quality and completeness of information provided to the forensic person who determines the cause and manner of death [8].

Fatal injuries may be affected by drugs, alcohol or poisons, which can be identified by toxicological analysis and assist with clarifying the injury [9,10].

Histopathological examination can be helpful in determining tissue vitality and the chronology and mechanisms of injury which are not evident grossly [11,12]. In addition, apparently similar injuries can be completely different based on contextual information and scene findings [13,14]. Therefore, a systematic analysis of the injury pattern, clinical characteristics, circumstantial factors and forensic information can give a more complete description of fatal medicolegal cases.

Research Objective

To analyze fatal medicolegal cases with respect to injury patterns, clinical characteristics, circumstantial factors, and available forensic evidence, and to determine their relationship with the cause and manner of death.

Study Design and Setting A retrospective observational study was carried out in Pakistan. It is a major tertiary care referral hospital which receives patients from all over city and its surrounding districts, and offers medicolegal and postmortem services for patients who die in suspicious circumstances, accidental, suicidal, homicidal and all other cases. The study was a systematic review of all medicolegal cases which resulted in death in the institution. This study was conducted over a 12-month period, from January 2025 to December 2025. Study Population All the deceased persons who were referred to the medicolegal service of Lady Reading Hospital for medicolegal investigation and post mortem examination during the study period constituted the study population. Demographic, injury, clinical, circumstances of death and available forensic evidence were evaluated. Twenty-nine hundred and ten medicolegal cases were included in the study which met the eligibility criteria and for which there were fatalities. Sample Size and Sampling Technique Consecutive sampling was used to include 290 cases. All cases of fatal medicolegal death seen throughout the study period were eligible for inclusion, until the desired number of cases was reached. To ensure a 100% coverage of eligible cases and minimise selective case inclusion, consecutive sampling was used. Eligibility Criteria Medicolegal cases of all ages and both sexes were included, when they had been investigated and post-mortemed at Lady Reading Hospital during the study period, and were fatal. Cases were added where there was sufficient data on death circumstances, postmortem examination results and the principle variables of the study. Records that were incomplete or lacked information on characteristic, circumstances or cause of death were not used in the final analysis. Data Collection The structured data collection proforma was used to access a variety of data sources, including medicolegal examination reports, post mortem examination reports, hospital records, police/investigative records, and available forensic laboratory reports, to collect data.Data were retrieved using a structured data collection proforma from a variety of data sources, including medicolegal examination report, post mortem examination report, hospital record, police/investigative record and available reports from the forensic laboratory. Demographic variables were age and sex. Clinical and pathological variables were patients' clinical history, nature and number of injuries, location of the injuries, presence of associated fractures, presence of internal injuries, presence of haemorrhage, and visceral and organ involvement. Details of the circumstances of death, the reported mechanism of injury, site of the incident and the final opinion of the medicolegal investigator were also documented. Assessment of Injury Patterns Patterns of injuries were evaluated based on the type of injury, how the injury occurred, the anatomic distribution, number of injuries, and severity of injuries. If applicable, injuries were classified as blunt, sharp, gunshot, or any other trauma. The anatomical distribution was noted by body regions (head and neck, chest, abdomen, pelvis and extremities). Special focus was paid to deaths from brain injuries, major blood vessels, heart, lungs, liver, spleen, kidneys, and other organs. Other associated findings included fractures, bleeding, tissue destruction and involvement of multiple organs. Clinical and Demographic Characteristics Differences and similarities of demographic and clinically available data were explored for patterns within fatal medicolegal cases. The age was registered as continuous variable and also was classified as clinically relevant age groups for analysis. Information on sex, relevant medical history, pre-hospital or hospital treatment and clinical status prior to death was documented when available. For cases that did survive for some time after the injury, medical records were reviewed to find a correlation between initial injury and complications and final outcome. Circumstantial Factors Available police reports, medicolegal documentation, hospital records and other investigative records were used to obtain circumstantial characteristics. These variables were reported circumstances of death, place of death, presumed mechanism of death, and suspected manner of death. The cases were classified as accidental, suicidal, homicidal or undetermined based on the available medicolegal assessment. For those that occurred, details of road traffic collisions, falls, interpersonal violence, self-injury, occupational incidents, and other circumstances were taken. Forensic Evidence An evaluation of the available forensic evidence was conducted in order to evaluate its contribution to determining the cause and manner of death. This encompassed toxicological, histopathological, gunshot-related, biological, and other pertinent laboratory data, as applicable to the circumstances of each case. The presence of alcohol, drugs, poison or other substances that may have caused death, or affected the interpretation of the circumstances, was evaluated. Histopathological and other ancillary findings were compared with gross post mortem observations wherever possible. Determination of Cause and Manner of Death The final cause of death was determined by a combination of circumstantial information, clinical history, external and internal postmortem examination, and available forensic investigations. The primary fatal injury or pathological process was identified in cases involving multiple injuries. The manner of death was determined by the final medicolegal opinion recorded in the case records as either accidental, suicidal, homicidal, or undetermined. Pre-final classification was made in cases where the circumstantial information and pathological examination did not match, taking into consideration the available forensic data. Data Quality Assurance A data collection proforma was used to obtain the data to ensure uniformity in retrieval. Data was checked for completeness and consistency and discrepancies were compared with the original medicolegal and post mortem records. First, data was coded prior to statistical analysis and second, personally identifiable data were removed from the analysis data set to ensure confidentiality. Statistical Analysis The data were analyzed statistically using IBM SPSS Statistics, version 26.0. Categorical variables were summarized as frequency and percentage, and continuous variables were summarized as mean ± standard deviation or median with interquartile range and were dependent on the distribution of the data. The relationships between various demographic variables, injury pattern, circumstantial variables, forensic variables and the manner of death were evaluated using chi-square test or Fisher's exact test where applicable. The t test for independent samples or Mann– Whitney U test was used for continuous variables based on distribution. If applicable, multivariable logistic regression was used to determine factors independently associated with the principal outcome. A p value <0.05 (two-sided) was taken as statistically significant.

Table 1 shows that the study included 290 fatal medicolegal cases, with a mean age of 39.7 ± 18.2 years. The largest age group was 21–30 years, comprising 71 (24.48%) cases, followed by 31–40 years with 63 (21.72%) cases. Males predominated, accounting for 226 (77.93%) cases, compared with 64 (22.07%) females.

 Blunt-force trauma was the most frequent injury mechanism, reported in 136 (46.90%) cases, followed by sharp-force injuries in 47 (16.21%) and firearm injuries in 38 (13.10%). Head and neck injuries were the most common anatomical injuries (154, 53.10%), while internal hemorrhage was the most frequent major postmortem finding (139, 47.93%).

Table 1. Demographic and Clinical Characteristics, Injury Patterns, and Postmortem Findings of Fatal Medicolegal Cases (n=290)

Table 2 demonstrates that road traffic collisions were the most frequently reported circumstance of death, accounting for 118 (40.69%) cases, followed by interpersonal violence or assault in 63 (21.72%) cases and falls in 34 (11.72%) cases. Firearm-related incidents accounted for 38 (13.10%) cases, while self-inflicted injuries were reported in 24 (8.28%) cases. Regarding the location of occurrence, roads or highways were the most common sites, involving 121 (41.72%) cases, followed by residences with 65 (22.41%) cases and public places with 47 (16.21%) cases.

Table 2. Circumstantial Characteristics of Fatal Medicolegal Cases (n=290)

Table 3 presents the available forensic and ancillary investigation findings. Toxicological examination was performed in 108 (37.24%) cases, with positive findings documented in 43 (14.83%). Histopathological examination was performed in 82 (28.28%) cases, of which 49 (16.90%) demonstrated significant histopathological findings.

Firearm-related forensic evidence was documented in 38 (13.10%) cases, while biological or trace evidence was identified in 54 (18.62%). No additional forensic evidence was documented in 117 (40.34%) cases.

Table 3. Forensic Evidence and Ancillary Investigation Findings (n=290)

Table 4 shows that traumatic brain injury was the leading principal cause of death, accounting for 91 (31.38%) cases, followed by hemorrhagic shock in 65 (22.41%) and multiple traumatic injuries in 52 (17.93%) cases. Thoracic injury accounted for 29 (10.00%) deaths, while abdominal or visceral injuries accounted for 22 (7.59%).

 Regarding manner of death, 169 (58.28%) cases were classified as accidental, 67 (23.10%) as homicidal, 32 (11.03%) as suicidal, and 22 (7.59%) as undetermined.

Table 4. Cause and Manner of Death Among Fatal Medicolegal Cases (n=290)

Table 5 demonstrates significant associations between injury characteristics and manner of death. Blunt-force injuries were predominantly observed among accidental deaths, whereas sharp-force and firearm injuries were more frequently associated with homicidal deaths, with all three associations statistically significant (p<0.001).

 Multiple injuries were also significantly associated with manner of death (p=0.021). Head injuries (p=0.018) and internal hemorrhage (p=0.006) likewise showed statistically significant associations with manner of death.

Table 5. Association Between Major Injury Characteristics and Manner of Death

Table 6 compares accidental with non-accidental fatalities. The mean age was 41.2 ± 19.1 years among accidental fatalities and 37.6 ± 17.4 years among non-accidental fatalities, with no significant difference (p=0.094).

 Multiple body-region injuries were significantly more frequent among non-accidental fatalities (45.45% vs. 33.73%; p=0.045). Sharp-force injuries, firearm injuries, and assault-related circumstances were significantly more common among non-accidental fatalities, whereas blunt-force injuries and road traffic collisions were significantly more frequent among accidental fatalities (all p<0.001).

Positive toxicology (p=0.985) and histopathological examination (p=0.320) did not differ significantly between the two groups.

Table 6. Comparison of Demographic, Injury, Circumstantial, and Forensic Characteristics Between Accidental and Non-Accidental Fatalities

Note: Continuous variables were compared using the independent-samples t test or Mann–Whitney U test according to distribution, while categorical variables were analyzed using the chi-square test or Fisher’s exact test, as appropriate.

In the current study, the predominant age group was the young and middle age group with mean age of 39.7 ± 18.2 years and 46.20% of the cases were in the age group of 21–40 years. The study population showed a high male predominance with 77.93% of individuals being male. This is similar to previous forensic studies that have identified that males of working age are more likely to sustain a fatal traumatic injury. A male to female ratio of 2.6:1 has been reported in 372 fatal autopsies for head trauma, most of which took place in males < 45 years old [15]. The relatively low number of females may be because they are more likely to be protected from external hazards such as road traffic, work-related, interpersonal and other risks, as indicated by the higher proportion of young adult males in the study. In the present study, blunt-force trauma was the most common mechanism of injury, followed closely by sharp-force trauma and firearm trauma, with 136 (46.90%) cases, 47 (16.21%) cases, and 38 (13.10%) cases, respectively. This distribution differs slightly from those studies limited to homicidal deaths where there may be a more equal distribution of sharp and blunt trauma. Such as, in a five-year study of homicidal deaths in Malaysia, sharp force trauma was the mechanism in 33% while one-quarter of the homicides were caused by asphyxial and firearm trauma [16]. The considerable number of accidental injuries, including road traffic collisions, in our total medicolegal population is likely to explain this ratio of blunt trauma, and not only homicide. In this study, head and neck injuries were most common (154 cases, 53.10%), with 117 cases (40.34%) of intracranial injury, 83 cases (28.62%) of skull fractures and 139 cases (47.93%) of internal haemorrhage. These conclusions are similar to the autopsy results obtained in Pakistan. In previous studies, head injury was reported to be responsible for the death in 64.6% of road traffic accident fatalities and skull fractures were the most common fracture pattern (53%) [17]. Likewise, 78.2% of fatalities from head trauma had skull fractures and 80.6% had intracranial hemorrhage according to Kronsbein et al., (2020) [15]. Our study population included all the fatal medicolegal mechanisms, resulting in somewhat lower frequencies; this is to be expected, as no other study of fatal head trauma has included all such mechanisms. The most frequently reported circumstance in the present study was road traffic collisions (118; 40.69%) and the most common incident site was roads or highway (121; 41.72%). This discovery further underlines the existing significance of road traffic injuries in the context of medicolegal practice in Pakistan. Road traffic injuries were also found to be a significant cause of death in Karachi with the majority of fatalities being due to head injury and multiple trauma, as found by Khurshid et al., (2021) [17]. The present study showed that in addition to the effects of accidental trauma, fatal medicolegal deaths encompass interpersonal violence/assault (63, 21.72%) and self-inflicted injuries (24, 8.28%). Thus, the distribution of circumstances highlights the need to consider scene information in conjunction with autopsy data, not just autopsy data. In a significant percentage of cases, forensic investigations gave further information. Toxicological examination was done in 108 (37.24%) cases which were positive in 43 (14.83%) and histopathological examination was undertaken in 82 (28.28%) cases, with significant findings in 49 (16.90%). The firearm related forensic evidence was documented in 38 (13.10%) and biological/trace evidence was documented in 54 (18.62%). Expanding toxicological testing revealed important drugs and led to changes in the recorded cause or manner of death in some of the cases and was supported by the study by Schreiber and Peterson [18]. Similarly, the examination of gunshots using the scientific method of a ballistics autopsy can help with the determination of manner of death when combined with other investigative facts. Traumatic brain injury was discovered to be the highest cause of death (91, 31.38%), followed by hemorrhagic shock (65, 22.41%) and multiple traumatic wounds (52, 17.93%). Accidental deaths predominated (169, 58.28%), followed by homicidal (67, 23.10%), suicidal (32, 11.03%), and undetermined deaths (22, 7.59%). Importantly, manner of death was significantly associated with blunt force, sharp force and gunshot wounds (all p<0.001), as well as head injury (p=0.018) and internal hemorrhage (p=0.006). These results are similar to those of Forensic analyses that have shown that injury characteristics can aid in the distinction between homicide and suicide, especially sharp force injuries [19]. Sharp force injury, firearm injury, assault-related circumstances and multiple injuries to the body region were significantly more prevalent among non-accidental deaths, while blunt trauma and road traffic collisions were strongly associated with accidental deaths (all p<0.001) were present in this comparison. These findings are consistent with adopting a holistic medicolegal strategy that provides for the integration of injury morphology, circumstances, and ancillary forensic evidence to formulate the most defensible cause and manner of death. To this end, research has indicated that circumstances surrounding the investigation can have a significant impact upon a manner of death determination even when the autopsy results are the same [20]. Strengths and Limitations One of the most significant strengths of this study is that it was able to evaluate all medicolegal deaths comprehensively, combining demographic, injury patterns, anatomical findings, circumstantial details, cause and manner of death and available forensic evidence into one study population. The consumption of multiple medicolegal, postmortem, clinical, investigative and forensic records experienced over the specified 12-month period and the application of consecutive sampling allowed for the broad coverage of fatal cases handled within a major tertiary-care centre. There are, however, some restrictions to be taken into account. The single-center retrospective design restricts the generalizability to other regions and institutions and the use of existing records may have led to the lack of completeness and/or inconsistencies in circumstantial and forensic data. Selective use of ancillary investigations, which may cause information bias, was performed. Furthermore, the observational nature of the study does not allow for causal inferences, and the results could not necessarily reflect the entire medicolegal fatal drug fatalities that are managed outside the hospital or fatal drug deaths that are not fully documented.

Table 1 shows that the study included 290 fatal medicolegal cases, with a mean age of 39.7 ± 18.2 years. The largest age group was 21–30 years, comprising 71 (24.48%) cases, followed by 31–40 years with 63 (21.72%) cases. Males predominated, accounting for 226 (77.93%) cases, compared with 64 (22.07%) females.

 Blunt-force trauma was the most frequent injury mechanism, reported in 136 (46.90%) cases, followed by sharp-force injuries in 47 (16.21%) and firearm injuries in 38 (13.10%). Head and neck injuries were the most common anatomical injuries (154, 53.10%), while internal hemorrhage was the most frequent major postmortem finding (139, 47.93%).

Table 1. Demographic and Clinical Characteristics, Injury Patterns, and Postmortem Findings of Fatal Medicolegal Cases (n=290)

Table 2 demonstrates that road traffic collisions were the most frequently reported circumstance of death, accounting for 118 (40.69%) cases, followed by interpersonal violence or assault in 63 (21.72%) cases and falls in 34 (11.72%) cases. Firearm-related incidents accounted for 38 (13.10%) cases, while self-inflicted injuries were reported in 24 (8.28%) cases. Regarding the location of occurrence, roads or highways were the most common sites, involving 121 (41.72%) cases, followed by residences with 65 (22.41%) cases and public places with 47 (16.21%) cases.

Table 2. Circumstantial Characteristics of Fatal Medicolegal Cases (n=290)

Table 3 presents the available forensic and ancillary investigation findings. Toxicological examination was performed in 108 (37.24%) cases, with positive findings documented in 43 (14.83%). Histopathological examination was performed in 82 (28.28%) cases, of which 49 (16.90%) demonstrated significant histopathological findings.

Firearm-related forensic evidence was documented in 38 (13.10%) cases, while biological or trace evidence was identified in 54 (18.62%). No additional forensic evidence was documented in 117 (40.34%) cases.

Table 3. Forensic Evidence and Ancillary Investigation Findings (n=290)

Table 4 shows that traumatic brain injury was the leading principal cause of death, accounting for 91 (31.38%) cases, followed by hemorrhagic shock in 65 (22.41%) and multiple traumatic injuries in 52 (17.93%) cases. Thoracic injury accounted for 29 (10.00%) deaths, while abdominal or visceral injuries accounted for 22 (7.59%).

 Regarding manner of death, 169 (58.28%) cases were classified as accidental, 67 (23.10%) as homicidal, 32 (11.03%) as suicidal, and 22 (7.59%) as undetermined.

Table 4. Cause and Manner of Death Among Fatal Medicolegal Cases (n=290)

Table 5 demonstrates significant associations between injury characteristics and manner of death. Blunt-force injuries were predominantly observed among accidental deaths, whereas sharp-force and firearm injuries were more frequently associated with homicidal deaths, with all three associations statistically significant (p<0.001).

 Multiple injuries were also significantly associated with manner of death (p=0.021). Head injuries (p=0.018) and internal hemorrhage (p=0.006) likewise showed statistically significant associations with manner of death.

Table 5. Association Between Major Injury Characteristics and Manner of Death

Table 6 compares accidental with non-accidental fatalities. The mean age was 41.2 ± 19.1 years among accidental fatalities and 37.6 ± 17.4 years among non-accidental fatalities, with no significant difference (p=0.094).

 Multiple body-region injuries were significantly more frequent among non-accidental fatalities (45.45% vs. 33.73%; p=0.045). Sharp-force injuries, firearm injuries, and assault-related circumstances were significantly more common among non-accidental fatalities, whereas blunt-force injuries and road traffic collisions were significantly more frequent among accidental fatalities (all p<0.001).

Positive toxicology (p=0.985) and histopathological examination (p=0.320) did not differ significantly between the two groups.

Table 6. Comparison of Demographic, Injury, Circumstantial, and Forensic Characteristics Between Accidental and Non-Accidental Fatalities

Note: Continuous variables were compared using the independent-samples t test or Mann–Whitney U test according to distribution, while categorical variables were analyzed using the chi-square test or Fisher’s exact test, as appropriate.

In the current study, the predominant age group was the young and middle age group with mean age of 39.7 ± 18.2 years and 46.20% of the cases were in the age group of 21–40 years. The study population showed a high male predominance with 77.93% of individuals being male. This is similar to previous forensic studies that have identified that males of working age are more likely to sustain a fatal traumatic injury. A male to female ratio of 2.6:1 has been reported in 372 fatal autopsies for head trauma, most of which took place in males < 45 years old [15]. The relatively low number of females may be because they are more likely to be protected from external hazards such as road traffic, work-related, interpersonal and other risks, as indicated by the higher proportion of young adult males in the study. In the present study, blunt-force trauma was the most common mechanism of injury, followed closely by sharp-force trauma and firearm trauma, with 136 (46.90%) cases, 47 (16.21%) cases, and 38 (13.10%) cases, respectively. This distribution differs slightly from those studies limited to homicidal deaths where there may be a more equal distribution of sharp and blunt trauma. Such as, in a five-year study of homicidal deaths in Malaysia, sharp force trauma was the mechanism in 33% while one-quarter of the homicides were caused by asphyxial and firearm trauma [16]. The considerable number of accidental injuries, including road traffic collisions, in our total medicolegal population is likely to explain this ratio of blunt trauma, and not only homicide. In this study, head and neck injuries were most common (154 cases, 53.10%), with 117 cases (40.34%) of intracranial injury, 83 cases (28.62%) of skull fractures and 139 cases (47.93%) of internal haemorrhage. These conclusions are similar to the autopsy results obtained in Pakistan. In previous studies, head injury was reported to be responsible for the death in 64.6% of road traffic accident fatalities and skull fractures were the most common fracture pattern (53%) [17]. Likewise, 78.2% of fatalities from head trauma had skull fractures and 80.6% had intracranial hemorrhage according to Kronsbein et al., (2020) [15]. Our study population included all the fatal medicolegal mechanisms, resulting in somewhat lower frequencies; this is to be expected, as no other study of fatal head trauma has included all such mechanisms. The most frequently reported circumstance in the present study was road traffic collisions (118; 40.69%) and the most common incident site was roads or highway (121; 41.72%). This discovery further underlines the existing significance of road traffic injuries in the context of medicolegal practice in Pakistan. Road traffic injuries were also found to be a significant cause of death in Karachi with the majority of fatalities being due to head injury and multiple trauma, as found by Khurshid et al., (2021) [17]. The present study showed that in addition to the effects of accidental trauma, fatal medicolegal deaths encompass interpersonal violence/assault (63, 21.72%) and self-inflicted injuries (24, 8.28%). Thus, the distribution of circumstances highlights the need to consider scene information in conjunction with autopsy data, not just autopsy data. In a significant percentage of cases, forensic investigations gave further information. Toxicological examination was done in 108 (37.24%) cases which were positive in 43 (14.83%) and histopathological examination was undertaken in 82 (28.28%) cases, with significant findings in 49 (16.90%). The firearm related forensic evidence was documented in 38 (13.10%) and biological/trace evidence was documented in 54 (18.62%). Expanding toxicological testing revealed important drugs and led to changes in the recorded cause or manner of death in some of the cases and was supported by the study by Schreiber and Peterson [18]. Similarly, the examination of gunshots using the scientific method of a ballistics autopsy can help with the determination of manner of death when combined with other investigative facts. Traumatic brain injury was discovered to be the highest cause of death (91, 31.38%), followed by hemorrhagic shock (65, 22.41%) and multiple traumatic wounds (52, 17.93%). Accidental deaths predominated (169, 58.28%), followed by homicidal (67, 23.10%), suicidal (32, 11.03%), and undetermined deaths (22, 7.59%). Importantly, manner of death was significantly associated with blunt force, sharp force and gunshot wounds (all p<0.001), as well as head injury (p=0.018) and internal hemorrhage (p=0.006). These results are similar to those of Forensic analyses that have shown that injury characteristics can aid in the distinction between homicide and suicide, especially sharp force injuries [19]. Sharp force injury, firearm injury, assault-related circumstances and multiple injuries to the body region were significantly more prevalent among non-accidental deaths, while blunt trauma and road traffic collisions were strongly associated with accidental deaths (all p<0.001) were present in this comparison. These findings are consistent with adopting a holistic medicolegal strategy that provides for the integration of injury morphology, circumstances, and ancillary forensic evidence to formulate the most defensible cause and manner of death. To this end, research has indicated that circumstances surrounding the investigation can have a significant impact upon a manner of death determination even when the autopsy results are the same [20]. Strengths and Limitations One of the most significant strengths of this study is that it was able to evaluate all medicolegal deaths comprehensively, combining demographic, injury patterns, anatomical findings, circumstantial details, cause and manner of death and available forensic evidence into one study population. The consumption of multiple medicolegal, postmortem, clinical, investigative and forensic records experienced over the specified 12-month period and the application of consecutive sampling allowed for the broad coverage of fatal cases handled within a major tertiary-care centre. There are, however, some restrictions to be taken into account. The single-center retrospective design restricts the generalizability to other regions and institutions and the use of existing records may have led to the lack of completeness and/or inconsistencies in circumstantial and forensic data. Selective use of ancillary investigations, which may cause information bias, was performed. Furthermore, the observational nature of the study does not allow for causal inferences, and the results could not necessarily reflect the entire medicolegal fatal drug fatalities that are managed outside the hospital or fatal drug deaths that are not fully documented.

The patterns of injury and circumstances in fatal medicolegal cases are variable, and there is significant blunt, sharp and gunshot wound trauma. The results highlight the value of a systematic postmortem investigation, along with clinical history, circumstantial data and proper forensic investigation, to establish a true cause and manner of death. Combining the medicolegal and forensic aspects of death certification can enhance the accuracy of the death certificate, facilitate forensic interpretation, and assist in injury prevention, medico-legal practice and public health planning.