Pretoria Medico-Legal Laboratory Research Articles

The Effect of the COVID-19 Pandemic on Suicide Trends in Pretoria, South Africa.

Suicide is one of the worldwide leading causes of unnatural death. Pretoria is a capital city of South Africa and is the fourth most populated city in South Africa. Between 16 and 22 suicide cases are recorded daily in South Africa.Case files from the Pretoria Medico-Legal Laboratory were reviewed between 1 January 2015 to 31 December 2021, which spanned the COVID-19 pandemic. All cases of possible and probable suicides were included. One-way analysis of variance and Pearson chi 2 tests were conducted to determine statistical significance in the observed trends.A total of 1820 possible and probable suicide cases were identified. The year following the outbreak of the COVID-19 pandemic accounted for the largest number of suicides. White males were the most heavily represented population, followed by Black males. Hanging was the most common method for males, whereas poisoning via ingestion and/or overdose was more commonly used by females.Suicides in Pretoria have increased since previous studies from 9.74% and 10.2% to 13.32%. Methods used have changed among various population groups over the past two decades. This paper examined changes in suicide trends in Pretoria compared to previous studies and highlighted correlations between suicide trends and COVID-19 lockdown measures.

Deaths due to police action and custody deaths: a persistent problem in Pretoria, South Africa

In 2013, South Africa had the second highest rate of imprisonment in Africa. During the apartheid era, a substantial number of deaths in custody involved political detainees. However, two decades after the abolition of apartheid there continues to be a high number of deaths in custody and deaths due to police action.
 There is no internationally standardised classification for deaths which take place in custody and/or due to police action. For purposes of this study, we divided these cases broadly into two categories: firstly, deaths which took place as a result of police action as well as deaths of persons held in police custody, and secondly, deaths of inmates of correctional service facilities. We conducted a retrospective descriptive case audit at the Pretoria Medico-Legal Laboratory (PMLL) of all cases admitted as deaths as a result of police action, deaths in police custody and deaths in correctional service facilities during the five year period from January 2007 through December 2011. A total of 93 cases were identified, which included 48 deaths due to police action, 28 deaths in police custody and 17 deaths in correctional service custody. The majority of these deaths were due to gunshot wounds (n=48), and all of these occured due to police action. Hangings accounted for 17 cases, the majority of which happened in police holding cells. The study highlights the relatively large numbers of firearm fatalities related to police action. In contrast to similar studies elsewhere, we found no deaths due to phenomena such as excited delirium or deaths associated with illicit drug intoxication. We conclude that there is a need for objective, impartial and competent medico-legal investigation into deaths of this nature.

Deaths due to police action and deaths in custody - A persistent problem in Pretoria, South Africa

In 2013, South Africa had the second highest rate of imprisonment in Africa. During the apartheid era, a substantial number of deaths in custody involved political detainees. However, two decades after the abolition of apartheid there continues to be a high number of deaths in custody and deaths due to police action.
 There is no internationally standardised classification for deaths which take place in custody and/or due to police action. For purposes of this study, we divided these cases broadly into two categories: firstly, deaths which took place as a result of police action as well as deaths of persons held in police custody, and secondly, deaths of inmates of correctional service facilities. We conducted a retrospective descriptive case audit at the Pretoria Medico-Legal Laboratory (PMLL) of all cases admitted as deaths as a result of police action, deaths in police custody and deaths in correctional service facilities during the five year period from January 2007 through December 2011. A total of 93 cases were identified, which included 48 deaths due to police action, 28 deaths in police custody and 17 deaths in correctional service custody. The majority of these deaths were due to gunshot wounds (n=48), and all of these occured due to police action. Hangings accounted for 17 cases, the majority of which happened in police holding cells. The study highlights the relatively large numbers of firearm fatalities related to police action. In contrast to similar studies elsewhere, we found no deaths due to phenomena such as excited delirium or deaths associated with illicit drug intoxication. We conclude that there is a need for objective, impartial and competent medico-legal investigation into deaths of this nature.

Medicolegal perspectives of interpersonal violence: A review of first-contact clinical notes.

South Africa has one of the highest rates of interpersonal violence (IPV), in all its forms, in the world. Incidents of assault are largely under-reported and place an immense burden on the healthcare, fiscal and judicial systems. The first contact a victim of IPV has with a medical practitioner may be the only opportunity to identify, record and preserve valuable evidence, as evidence not captured on this occasion may be lost forever. The accuracy and quality of clinical notes taken at the time may be of paramount importance in facilitating the administration of justice. (i) To investigate the adequacy of medicolegal note keeping by doctors in cases where subsequent legal proceedings may ensue; and (ii) to apprise clinicians of their shared responsibility in contributing to the administration of justice through both appropriate patient management and objective and contemporaneous recording of findings from a medicolegal perspective. A prospective descriptive study was conducted over a period of 18 months from 2016 to 2018. The investigators reviewed patient files and critically appraised first-contact clinical notes in fatal-outcome cases of IPV admitted to the Pretoria Medico-Legal Laboratory during the study period. The cases were reviewed using rubrics specifically designed by the investigators to critically but consistently assess the adequacy of documentation of the medicolegal aspects applicable to each case. One hundred cases met the defined criteria for inclusion in the study. The victims were predominantly male (98%), and most (79%) were aged <40 years. Blunt-force injuries were the most frequent type of injury (43%), while gunshot wounds accounted for 36% of cases and sharp-force injuries were documented in 11%. Insufficient medicolegal documentation, wound description and evidence collection, by medical practitioners, was identified across all wounding modalities in the study sample. This study showed that medicolegal documentation in cases of IPV is suboptimal, with many important parameters not being routinely recorded, which is likely to impact negatively on criminal investigations and downstream legal proceedings. Greater emphasis on these issues is required during the undergraduate training of healthcare workers in a society as severely afflicted by IPV as SA. Although this study focused on fatal-outcome cases, these conclusions are equally applicable to many more cases where investigators, prosecutors and presiding judicial officers may be dependent on findings contemporaneously and objectively recorded by medical professionals.

Thermal fatalities in Pretoria: A 5-year retrospective review

In South Africa, research on burn mortality has emanated primarily from specialised burn centres and has focused on specific age groups and hospital-based fatalities. This study describes the demographic profile and the pathology of trauma related to burn fatalities as seen at the Pretoria Medico-Legal Laboratory (PTA MLL), a large urban medico-legal mortuary over a 5-year period from January 2011 to December 2015. Mortuary admission records and autopsy reports were used to gather information on demographics, circumstances of injury, apparent manner and cause of death, pathology of burns, toxicology and histology reports and identification of the decedents. ResultsOf the 9558 unnatural deaths admitted to the PTA MLL during this time period, 291 (3.0%) of the fatalities met the inclusion criteria. The male:female ratio was 2.9:1. Most fatalities occurred between the ages of 0–4 years. One hundred and forty-two (142) decedents were charred beyond recognition. Identification was confirmed in 134 (94.4%) of the charred remains. In 208 (69.8%) of the cases the manner of death was deemed to be accidental, 23 (7.9%) were homicidal and 11 (3.8%) were suicides. Two hundred and fifty-five (87.4%) of the fatalities were as a result of open flames/fires. Shack fires were responsible for 105 (36%) of all fatalities. In 32 (11.0%) cases of open flame/fire fatalities where death occurred at the scene of injury, more than one fatality was reported per incident. In 122 (79.2%) of scene fatalities, soot deposition was noted in the upper and lower airways. Forty-five (32.8%) of hospital fatalities occurred within 24 h of admission. The most common complications in hospital fatalities were from the respiratory system. The mean blood alcohol concentrations (BAC) was 0.09 g/100 ml. The mean carboxyhaemoglobin concentrations (COHb) was 19.9%. All available cyanide results were negative. ConclusionThe study is the first of its kind in South Africa to generate bimodal descriptive statistics for burn fatalities. Approximately 3% of unnatural deaths at the PTA-MLL were due to burns, occurring at a rate of ±1 death per week. The data provides a platform for funding, collaborative research, planning and development of public health programs.

Feasibility of analysis of the SCN5A gene in paraffin embedded samples in sudden infant death cases at the Pretoria Medico-Legal Laboratory, South Africa.

To determine variations in the SCN5A gene linked to inherited cardiac arrhythmogenic disorders in sudden, unexplained infant death (SUID) cases examined at the Pretoria Medico-Legal Laboratory, South Africa. A retrospective study was conducted on SUID cases and controls, analyzing DNA extracted from archived formalin-fixed, paraffin-embedded (FFPE) myocardial tissue samples as well as blood samples. A total of 48 FFPE tissue samples (cases), 10 control FFPE tissue samples and nine control blood samples were included. DNA extracted from all samples was used to test for variations in the SCN5A gene by using high resolution melt (HRM) real-time PCR and sequencing. Genetic analysis showed 31 different single nucleotide variants in the entire study population (n = 67). Five previously reported variants of known pathogenic significance, and 14 variants of benign clinical significance, were identified. The study found 12 different variants in the cases that were not published in any database or literature and were considered novel. Of these novel variants, two were predicted as "probably damaging" with a high level of certainty (found in four case samples), one (identified in another case sample) was predicted to be "possibly damaging" with a 50% chance of being disease-causing, and nine were predicted to be benign. This study shows the significant added value of using genetic testing in determining the cause of death in South African SUID cases. Considering the high heritability of these arrhythmic disorders, post mortem genetic testing could play an important role in the understanding of the pathogenesis thereof and could also aid in the diagnosis and treatment of family members at risk, ultimately preventing similar future cases.

Suicide in Pretoria: A retrospective review, 2007 - 2010.

The World Health Organization has declared suicide a global ealth crisis, predicting that ~1.53 million people will commit suicide annually by 2020. A study from South Africa reviewed 1 018 suicide cases in Pretoria over 4 years (1997 - 2000). Our study was undertaken to establish whether there have been substantial changes in the profile of suicide victims who died in Pretoria a decade later. Case records at the Pretoria Medico-Legal Laboratory were reviewed retrospectively from 2007 to 2010. A total of 957 suicide cases were identified. Hanging was the most common method of suicide, followed by self-inflicted firearm injury. The true incidence of suicidal intake of prescription drugs/medication was difficult to determine, because of a backlog at the state toxicology laboratories. White males and females appeared to be over-represented among suicide victims, but there has been an increase in suicide among blacks. There seems to have been a substantial decrease in the use of firearms to commit suicide - possibly reflecting a positive outcome of gun control legislation that has been introduced in the interim. Suicide continues to constitute almost 10% of all fatalities admitted to the Pretoria Medico-Legal Laboratory, confirming suicide as a major cause of mortality in our society. Further research is needed to clarify the profile of suicidal deaths, with a view to informing resource allocation and to improve preventive strategies.

Fatalities involving illicit drug use in Pretoria, South Africa, for the period 2003 - 2012.

Globally, illicit drugs are responsible for many fatalities annually, yet accurate data on the nature and extent of these deaths in South Africa (SA) are lacking. To investigate the presence and profile of illicit drugs detected in deceased persons who were subjected to medicolegal autopsies and upon whom analyses were carried out in search of illicit drugs in their body fluids at the Pretoria Medico-Legal Laboratory (PMLL), SA, over a 10-year period. A retrospective descriptive case audit was conducted for the period 2003 - 2012. Screening for illicit drugs was requested in 385 out of 22566 medicolegal autopsies. Results were available for only 281 of these cases, with 154 cases showing the presence of one or more illicit drugs. The demographic profile of positive cases indicated the majority to be male (90.3%) and white (85.1%). Decedents who tested positive for illicit drugs were predominantly aged between 20 and 30 years (51.9%). The most frequently detected drug was heroin, the presence of which was confirmed in 35.2% of cases, followed by cocaine in 19.9%. Alcohol in combination with an illicit drug or drugs was detected in 56 cases (36.4%). Results from this study indicate that illicit drugs were implicated in a considerable number of fatalities in Pretoria. However, it is believed that the figures are a gross under-representation of the actual number of drug users who died during this period. It is therefore recommended that further research be conducted and that drug screening be requested routinely when unnatural deaths are investigated at medicolegal mortuaries, not only to ensure the administration of justice but also to obtain more accurate data for purposes of public health programmes and improve insight into the burden of illicit drug use in SA.

Sudden and unexpected childhood deaths investigated at the Pretoria Medico-Legal Laboratory, South Africa, 2007-2011

Background. Sudden and unexpected death is well known to occur in infants, and although sudden deaths are less frequent after the first birthday, they still account for a significant proportion of childhood deaths. In 2009, 1.9% of the total deaths in the USA were childhood deaths. In South Africa (SA) this proportion was much higher at 11.85%. According to the law, sudden and unexpected deaths are generally investigated as unnatural deaths. Establishing an exact underlying anatomical cause of death will depend on available resources and can be difficult in a substantial proportion of cases. Methods. A retrospective descriptive case audit was conducted at the Pretoria Medico-Legal Laboratory (PMLL), SA, from 1 January 2007 through to 31 December 2011. All children aged 1 - 18 years who died suddenly and unexpectedly were included. Results. Ninety-eight cases were identified, which constituted nearly 1% of total admissions to the PMLL. The majority of the deaths were of children aged 1 - 5 years, and the male/female ratio was 1.04:1. In the largest proportion of cases ( n =28, 28.6%), the medicolegal investigation, including autopsy and ancillary investigations, did not establish an underlying anatomical cause of death. In the cases where a cause of death was established, pneumonia was the most common diagnosis ( n =22, 22.4%). Conclusion. The fact that the cause of the largest proportion of deaths could not be ascertained emphasises the need for consideration of additional investigative techniques, such as molecular/genetic screening, which have provided an underlying cause of death in a significant number of cases in other countries. There is a lack of published research on the causes and incidence of sudden unexpected deaths in children in SA, and further research in this area is needed.

Sudden and unexpected childhood deaths investigated at the Pretoria Medico-Legal Laboratory, South Africa, 2007 - 2011.

Sudden and unexpected death is well known to occur in infants, and although sudden deaths are less frequent after the first birthday, they still account for a significant proportion of childhood deaths. In 2009, 1.9% of the total deaths in the USA were childhood deaths. In South Africa (SA) this proportion was much higher at 11.85%. According to the law, sudden and unexpected deaths are generally investigated as unnatural deaths. Establishing an exact underlying anatomical cause of death will depend on available resources and can be difficult in a substantial proportion of cases. A retrospective descriptive case audit was conducted at the Pretoria Medico-Legal Laboratory (PMLL), SA, from 1 January 2007 through to 31 December 2011. All children aged 1 - 18 years who died suddenly and unexpectedly were included. Ninety-eight cases were identified, which constituted nearly 1% of total admissions to the PMLL. The majority of the deaths were of children aged 1 - 5 years, and the male/female ratio was 1.04:1. In the largest proportion of cases (n=28, 28.6%), the medicolegal investigation, including autopsy and ancillary investigations, did not establish an underlying anatomical cause of death. In the cases where a cause of death was established, pneumonia was the most common diagnosis (n=22, 22.4%). The fact that the cause of the largest proportion of deaths could not be ascertained emphasises the need for consideration of additional investigative techniques, such as molecular/genetic screening, which have provided an underlying cause of death in a significant number of cases in other countries. There is a lack of published research on the causes and incidence of sudden unexpected deaths in children in SA, and further research in this area is needed.

The prevalence of HIV in the sudden, unexplained and unexpected death population at the Pretoria Medico-Legal Laboratory.

PurposeTo determine the prevalence of HIV in the sudden, unexplained and unexpected (SUU) death population admitted to the Pretoria Medico-Legal Laboratory.MethodsThis study was conducted at the Pretoria Medico-Legal Laboratory. Blood samples were obtained from decedents who died suddenly and/or unexpectedly, during autopsy, by a forensic pathologist. Sample collection continued until 100 valid samples were analysed for HIV antibodies. The data collected included demographic details and case-related information.Results and ConclusionSUU deaths accounted for 14% of all cases admitted to the Pretoria Medico-Legal Laboratory. The HIV prevalence in the SUU deaths was 43%, which is 17% higher than the general mortuary population in Pretoria (p = 0.0045). The majority of these deaths were due to respiratory disease processes, with 12 cases having HIV/TB co-infection.

Childhood and adolescent fatalities at the Pretoria Medico-Legal Laboratory: 2005 - 2009

Background. Children and young adults are particularly vulnerable to intentional and accidental fatal injuries. The majority of deaths in Africa in children <5 years of age are due to infectious diseases. Road traffic fatalities constitute a large proportion of deaths in children and young adults worldwide. Objective. To evaluate the demographic details, external cause/circumstance of death and manner of death in children and young adults admitted to the Pretoria Medico-Legal Laboratory (PMLL). Methods. A retrospective case audit was conducted on all persons aged 1 - 20 years admitted to the PMLL from January 2005 through December 2009. Results. A total of 965 cases were identified. Childhood deaths constituted 7 - 9% of all cases admitted. The majority were aged between 16 and 20 years (42%), followed by children aged between 1 and 5 years (33%). The most common cause of death was injury due to road traffic accidents (this was present in all age groups). Conclusion. Children and young adults contribute a relatively large number of admissions to the medico-legal mortuary. The majority of these deaths are accidental. Many of the accidents could have been prevented with stricter legislation with regard to transportation of children and safety surrounding swimming pools.

The prevalence of HIV in the sudden, unexplained and unexpected death population at the Pretoria Medico-Legal Laboratory

The prevalence of HIV in the sudden, unexplained and unexpected death population at the Pretoria Medico-Legal Laboratory

Drowning in Pretoria, South Africa: A 10-year review

Drowning is classified as the 3rd leading cause of accidental deaths worldwide and is deemed to be a preventable cause of death. Bodies retrieved from a water medium pose several challenges to the forensic pathologist with the diagnosis of drowning being primarily one of exclusion. The aim of this study was to do a retrospective descriptive case audit of bodies retrieved from water and immersion related deaths, which were investigated at the Pretoria Medico-Legal Laboratory (PMLL) over a 10 year period (January 2002 through December 2011). A total of 346 cases were identified for inclusion into this study. In 6% (20) of these cases, the death was not related to drowning; in 14% (48) no clear cause of death could be ascertained and in 278 cases (80%) the cause of death was considered to have been due to drowning. Infants (under 1 year, of age) constituted 41 (15%) of the cases; toddlers (aged 1–2 years) comprised 52 (19%) cases; children (aged 2–13 years) 49 (18%) cases; adolescents (aged 13–18 years) comprised 10 (3%) cases; adults (above 18, years) made up 126 (45%) of the cases. The majority of the drownings, occurred in swimming pools [125 cases (38%)]. In infants 23 (56%) of, drownings occurred in swimming pools followed by buckets [7 cases (17%)]. Sixty-nine per cent of toddler drownings (36 cases) occurred in swimming, pools. In the adult population, 40 (32%) of cases occurred in pools and 35 cases (28%) in rivers. Positive blood alcohol results were recorded in 48, (42%) out of 113 cases where the test was requested, 40 (35%) of these, cases higher than 0.05 g per 100 ml. This study suggests that many drowning deaths in Pretoria may be preventable by introducing greater public awareness of the risks and instituting relatively simple, protective measures.

The medico-legal investigation of abandoned fetuses and newborns--a review of cases admitted to the Pretoria Medico-Legal Laboratory, South Africa.

There is a dearth of literature on the extent of fetal or newborn abandonment or "dumping" and the medico-legal investigation procedures these cases require. This is despite the fact that these occurrences are a worldwide phenomenon and by definition involve criminal law concerns such as illegal abortion, concealment of birth, murder, or neonaticide, depending on the country concerned. This article contributes to current literature in both respects and provides a retrospective case audit for the period 2004-2008 pertaining to all abandoned newborns and fetuses admitted to the Pretoria Medico-Legal Laboratory (PMLL) in South Africa. Demographic details, scope, and nature of the medico-legal investigation as well as formulation of cause of death were recorded. A total of 289 cases were identified for inclusion in this study, 57% of which were considered to have been non-viable fetuses, while 45 of the viable fetuses were deemed to have been stillborn. These instances involve the crimes of concealment of birth and at times illegal abortion, yet prosecution of these cases are relatively unheard of. Signs of live birth were identified in 38 of the cases in the study. Of these infants, 9 were deemed to have died from injuries they have sustained, and in a further 9 cases, no anatomical cause of death could be identified. Homicidal cases should be brought in cases where death ensued as a result of abandonment; however, it is not known how many cases were prosecuted. A comparatively large number of cases were found to have been admitted to the Pretoria Medico-Legal Laboratory. This is alarming because South African abortion laws are liberal and services are free at point of access in the public health care sector. A substantial percentage of cases of abandoned infants were found to have shown signs of life after birth implying a homicidal manner of death or death by abandonment, but it seems these cases are merely shelved.

The application of imaging technologies in the detection of trace evidence in forensic medical investigation

In a country notorious for violent crime, it seems that South African medico-legal laboratories make minimal application of technology in the death investigation process and little attention is given to trace evidence. Non-destructive, non-invasive, portable and cost-effective tools are required. This study was conducted at the Pretoria Medico-Legal Laboratory. The surface area of the bodies and clothing of victims of fatal interpersonal violence were examined using a torch, magnifying lamp, portable digital microscope and alternate light source to gauge their potential for trace evidence detection. Most studies apply these and similar tools to inert surfaces, with few focusing on their application to human skin. There was a statistically significant difference in the detection of many of the evidence types between the naked-eye observation of the pathologists and the technologies. The different imaging technologies were compared as to their cost, evidence detection ability and ease of use. The most common evidence types discovered on the bodies and clothing of victims of fatal interpersonal violence, as well as the propensity of each tool to detect these, was evaluated in order to devise the best option for incorporation into the Pretoria Medico-Legal Laboratory routine. The digital microscope performed best overall followed by the magnifying lamp, torch and the Polilight®. This study aimed to justify the investment of more time, effort and funding into trace evidence recovery in the South African mortuary environment.

The incidence, pathology of trauma and victim profiles of homicidal deaths in Pretoria, South Africa (2007–2008)

This study aimed to establish the incidence of homicide, associated pathology of trauma and victim profiles in cases admitted to or managed as homicidal deaths at the Pretoria Medico-Legal Laboratory (PMLL) over the period of 2007-2008. A total of 1088 cases were reviewed. Homicides accounted for 22.7% of all cases admitted to the PMLL. The majority of homicide victims were male individuals (87.0%). The most common cause of death was gunshot wounds (42.6%), followed by blunt force trauma (25.1%). Homicides are most likely to occur at the victim's place of residence (28.5%) and only 37.4% of victims survive long enough to receive hospital care. The results of this study seem to concur with international findings for the most part, with a few interesting deviations. Highlighting at-risk groups, as well as dangerous locations and incident times, creates the potential to decrease the occurrence of unnecessary deaths by generating an awareness of the trends.

A demographic study of homicide–suicide in the Pretoria region over a 5 year period

A study was undertaken to research the occurrence of homicide–suicide events in the Pretoria region from January 1997 until October 2001. It is important to attempt understanding this tragic phenomenon from psychiatric and forensic perspectives. This uncommon phenomenon has attracted widespread and sensational media coverage, but little is known about the causal factors and demographic profile of perpetrators and victims, and possible sites of intervention. Case files of the Pretoria Medico-Legal Laboratory (where all cases of unnatural death in Pretoria are investigated) were reviewed and information collected from relevant investigating officers of the South African Police Services. The average annual incidence of homicide–suicide in Pretoria over the period studied was found to be 1 per 100,000 of the population. Two profiles of typical perpetrators seem to emerge: a younger, single, black male shooting his girlfriend and himself at home; and an older, married, Caucasian male shooting his wife and himself at home. Employment in peace forces and unemployment are shown to play significant roles, suggesting need for the availability of psychological support systems to members of peace forces and for intervention regarding unemployment.