1

Causes of Non-natural deaths in Limpopo

Maimela E1, Thoka ME1, Bhootra BL2, Phooko J2, Mochaki K2.

1 Public Health Programmes, Limpopo Department of Health and Social Development. 2 Polokwane Forensic Pathology, Limpopo Department of Health and Social Development

Limpopo Department of Health

Introduction• Unnatural death

– Is a category used by coroners and vital statistics specialists for classifying all human deaths not properly describable as death by natural causes.

• Hence it would include events such as:– Accident– Execution– Homicide– Misadventure

• being attacked by insects, reptiles, fish, carnivorans, or other wildlife• adverse outcome of surgery

– NOTE: This is not failure of surgery

– Suicide– Terrorism– War

Introduction… • According to the Births, Marriages and Death Registration Act No 81 of

1963,

– A death certificate may be issued by a medical practitioner• When is regarded as solely and exclusively due to natural causes

• If the cause of death is suspected or known to be unnatural, which includes all traumatic deaths

– A medicolegal autopsy is requested in accordance with Inquest Act No 59 of 1959 and subsequent amendments

• After completion of medicolegal autopsy a form (Form GW7/15) is completed by the medical practitioners who performed the autopsy

– This form becomes a legal document for the information of the magistrate for subsequent legal procedures

METHODOLOGY• A retrospective review

– To determine the patterns of non-natural deaths in Limpopo, 2006 – 2011

– A special data sheet from Polokwane Forensic Pathology had variables such as:

• Age, gender, race, case number, cause of death, • And where available, suburb in which the accident occurred, whether the subject had

been admitted to hospital or not, cause of injury or non-natural death

• Data cleaning was done– Records with missing critical information were deleted

• Epi Info™ version 3.3.2 (2005) software was used to carry out data analysis.

Results

Results• A cumulative of 3 951 medicolegal autopsies were reviewed for

period 2006 – 2011

• Approximately 173 (4.4%) of the autopsy results were found to be deaths due to natural causes.

• Capricorn district had a significant higher percentages of autopsies performed (40%),

• Vhembe district had the second highest percentage of autopsies performed with an average of 21% for the review period

• Waterberg district had the lowest percentage of autopsies performed with an average of 8% for the review period

40%

19%

13%

21%

8%

Manner of non-natural deaths by district variations

CapricornMopaniSekhukhuneVhembeWaterburg

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

Manner of non-natural deaths, seasonal trends variations

201120102009200820072006

Axi

s T

itle

maternal deathmotor bike accident

multi organ failure, burns, cepticaemianon specified natural death

snake bitesubdural haemorrhage

abortionanaesthetic death

fallinghypovylaemic shock, brain damage, encephalopathy

lightiningsceptic shock, scepticaemia, sepsis

suspected poisoningfeotus

cardiac arrest, failure, arrthmia, haemorrhagestrangulation, throattling

poison ingestionUnspecified causes of death

murderdrowning

assaulthead, chest and neck injuries

unascertained due to decomposition, skeletal structureSevere burns

mva drivermultiple injuriesmva passenger

burnsmva pedestrian

Undetermined pending investigationsnatural causes

stab woundgun shothanging

blunt force injuriesmva

0.0% 5.0% 10.0% 15.0% 20.0% 25.0%

Manner of non-natural deaths

Manner of non-natural deaths

• The majority of non natural deaths were caused by road traffic injuries which constituted 25.7%

• Other important causes of deaths were – blunt force (assault/abuse) 15.9%, – hanging 8.9%, – sharp trauma 6.2%, – gunshot 5.2%, and – physical agents including stab wound 4.5%.

• Polokwane, St Rita’s and Tshilidzini hospitals had reported the highest number autopsies during 2008, 2009 and 2010 with a proportion of 21.8%, 14.1% and 12.4% respectively.

• Kgapane, Nkhensani and Maphutha Malatjie hospitals had a lowest autopsies during 2008, 2009 and 2010 with proportion of 2.4%, 2.9% and 3.2% respectively.

Female

foetus

Male

unspecified

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0%

22.6%

0.1%

75.7%

1.6%

Manner of non-natural deaths by victim gender

• There were significantly higher percentages of autopsies performed in males (75.7%).

• Foetus contributed approximately 0.1% of the autopsies performed

assa

ult

blunt

forc

e inj

uries

burn

s

chok

ing

drow

ning

elect

rocu

tion

fallin

g

gun

shot

haem

orrh

agic

shor

k

hang

ing

hypo

vylae

mic

shoc

k, b

rain

dam

age,

enc

epha

lopat

hy

light

ining

mot

or b

ike a

ccide

nt

mur

der

poiso

n ing

estio

n

scep

tic s

hock

, sce

ptica

emia,

sep

sis

Sever

e bu

rns

snak

e bit

e

stab

wou

nd

stra

ngula

tion,

thro

attlin

g

susp

ecte

d po

isonin

g

train

accid

ent

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%Manner of non-natural deaths by victim gender

Female

Male

<1 yr 1 - 4 yrs 5 - 9 yrs 10 - 14 yrs

15 - 19 yrs

20 - 24 yrs

25 - 29 yrs

30 - 34 yrs

35 - 39 yrs

40 - 44 yrs

45 - 49 yrs

50 - 54 yrs

55 - 59 yrs

60 - 64 yrs

>65 yrs0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%Manner of non-natural deaths by victim age and gender

FemaleMale

<1 yr

1 - 4 yrs

5 - 9 yrs

10 - 14 yrs

15 - 19 yrs

20 - 24 yrs

25 - 29 yrs

30 - 34 yrs

35 - 39 yrs

40 - 44 yrs

45 - 49 yrs

50 - 54 yrs

55 - 59 yrs

60 - 64 yrs

>65 yrs

0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0% 18.0%

Manner of non-natural deaths (blunt force injuries) by victim age stratified by gender

Male

Female

Axis Title

Ag

e in

yea

rs

Discussions • There were significantly higher percentages of autopsies performed in

males (75.5%).

• Foetus contributed approximately 0.1% of the autopsies performed

• A system has to be developed to monitor the medico-legal autopsies performed in the province in order to guide decision making.

• There are no epidemiological linkages with the overall manner of deaths – as the available data could not provide us with an opportunity to analyze the overall

manner of death per local areas.

Discussions… • According to the South African Mortality report for 2011,

– A proportion of 8.6% of all deaths were due to non-natural causes of death, with the majority of these due to other external causes of accidental injury.

– The highest percentage of deaths due to non-natural causes was observed for those aged 15 – 19 years when compared to other age groups

• This in contrast to our review– Because the highest percentage is observed in those aged 20 – 39 years;

– Our review concurs this study by showing that the number of deaths were generally higher for males compared to females.

Deaths due to accidents

• There was significant variation in the occurrence of deaths due to transport-related accidents

– MVA in general accounted for 20.1% followed by MVA pedestrian (3.4%), MVA passenger (3.2%), MVA driver (2.1%), Motor bike accident (0.2%) and lastly train accident which accounted for (0.1%)

– In United Sates during 2009, four major mechanisms of injury were poisoning, motor-vehicle traffic, firearm, and fall. All these accounted for 75.1% of all injury deaths.

Deaths due to Injuries…• Our review was consistent with other studies were in there was significant

variation in the occurrence of deaths due to injuries

– Blunt force injuries accounted for 15.9% which was the highest followed by gun shots (5.2%), stab wounds (4.9%), multiple injuries (3.2%), and lastly head, chest and neck injuries which accounted for 1.7%

• This coincide with the findings of studies of Fisher et al. (1994) and Perry and France (1998) in other countries.

• Other studies also revealed that deaths resulting from blunt force trauma are some of the most common cases encountered by the practicing forensic pathologist.

• Whereas other forms of traumatic death (eg, gunshot wounds, sharp force injuries) occur under a relatively limited number of circumstances.

Deaths due to Injuries….• For instance, almost all transportation fatalities result from blunt force

trauma– including those involving motor vehicle collisions, pedestrians being struck by

vehicles, airplane crashes, and boating incidents.

• Other deaths resulting from blunt force trauma involve– jumping or falling from heights, blast injuries, and being struck by a firm object,

such as a fist, crowbar, bat, or ball.

• In the current review there were approximately 0.3% of deaths due to falling– Included falling from house roof, wall, gate, ladder and in the toilet

Deaths due to Injuries….• Blunt force trauma is routinely involved in cases classified as

accidents, as well as in cases of suicide and homicide.

• People dying natural deaths often have minor blunt force injuries that do not contribute to death

– small abrasions or contusions on the skin are common place at autopsy.

– Although it is important to document evidence of blunt force trauma in all autopsies, one should not immediately assume that blunt force trauma is the cause of death.

Challenges

• Data had lots of missing variables

• Inconsistency in data capturing

• Non specified natural deaths

• Unspecified causes of deaths

• Undetermined due to pending investigations

Conclusion • In the present review, blunt head injuries especially homicidal were the

second leading cause of unnatural death, followed by stab in the chest whereas asphyxias especially smothering and hanging represented the minimal causes.

• This coincide with the findings of studies of Fisher et al. (1994) and Perry and France (1998) in other countries.

• In conclusion, – non-natural mortality surveillance is a useful tool in informing violence and injury prevention

initiatives.

– This type of surveillance is of value when analyzed on an ongoing basis.

– The system can further be strengthened by linking it with various systems such as death registration, hospital records, police accident and crime data as well as data from other agencies in related fields.

Recommendations• Leading causes of non natural deaths in the total population should be

determined by age, race, gender

• As the population continues to increase,– Preventive measures need to be taken to minimize unnatural deaths whether

homicidal, suicidal or accidental, based on the identified risk factors.

• Therefore, a more comprehensive and strict legislation should be considered to promote a non-violent community.

• In addition, improvement of roadways as well as strict traffic laws must be proposed to control traumatic accidental deaths.

Acknowledgement• Limpopo Provincial Forensic Pathology Unit (Polokwane)

• All government mortuaries for the collection of information.

• Epidemiology Sub-directorate under PHP.