Research Articles (Forensic Medicine)

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Suicidal iron and paracetamol overdose : a case report
(Lippincott Williams and Wilkins, 2025-03) Vandoorne, Carmen Zenda; carmen.weyers@up.ac.za
A woman presented to a hospital complaining of drowsiness and body weakness. The patient reported intentionally ingesting about 30 ferrous sulfate tablets and about 10 paracetamol tablets after an argument with a loved one. The ingestion occurred within 24 hours of presentation to hospital. Blood samples taken before any treatment was given demonstrated severe metabolic acidosis, leukocytosis, and liver impairment with raised aspartate transaminase (244 U/L), alanine transaminase (140 U/L), alkaline phosphatase (130 U/L) and conjugated bilirubin (9 μmol/L), and an international normalized ratio of 4.61 seconds. Serum paracetamol levels more than 12 hours after ingestion confirmed paracetamol toxicity at 433 μmol/L (reference range, >264 μmol/L). Serum iron studies showed raised transferrin at 5.07 g/L (reference range, 2.50–3.80 g/L) and normal ferritin at 58 μg/L (reference range, 10–291 μg/L); however, serum iron testing was rejected due to insufficient specimens. The patient underwent treatment including iron chelation therapy with desferrioxamine and acetylcysteine therapy for paracetamol overdose. Later, an upper gastrointestinal bleed was suspected due to a rapid drop in hemoglobin level from 10.5 g/dL to 5.1 g/dL. Despite appropriate medical treatment and cardiopulmonary resuscitation, the patient died approximately 24 hours after admission.
Penetrating crossbow injury to the head : a case of suicide
(Lippincott Williams and Wilkins, 2025-03) Joubert, Dorethea Maria; doret.joubert@up.ac.za
We present here the case of a 42-year-old male with a history of mental illness. There had been a previous attempt at suicide by similar means, using a firearm. He currently resided with family and was confined to bed for most of the day due to complications of abdominal injuries sustained during the previous suicide attempt; however, mobility was still possible. On the day of his demise, his mother looked in on him and found him dead on his bed with a bolt in his head and a crossbow in close proximity—next to his bed.
The effect of the COVID-19 pandemic on suicide trends in Pretoria, South Africa
(Lippincott Williams and Wilkins, 2024-09) Robinson, Kay-Leigh; Pretorius, Candice; Blumenthal, Ryan; Meyer, Pieter Willem Adriaan
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 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.
A 15-year review of lightning deaths in Germany-with a focus on pathognomonic findings
(Springer, 2024-07) Bingert, Rebecca; Bremer, Larissa; Buettner, Andreas; Nigbur, Stefan; Blumenthal, Ryan; Zack, Fred
Lethal accidents caused by lightning are divided into observed and unobserved events. Pathognomonic or characteristic findings are often overlooked during external postmortem examination. Classical mistakes may be made which may often lead to an incorrect diagnosis. An analysis of 270 fatalities was performed on a historical collection of the Committee for Lightning Conductor Construction for the United Economic Area e. V. (ABBW) on lethal accidents due to lightning that occurred in Germany for the period 1951–1965. Furthermore, a selective literature research was carried out. The aim of the study was to analyze the death scene, the clothing, and the victim. The authors focused on chief findings which were relevant to the correct diagnosis of “death by lightning.” Both Lichtenberg figures and singed body hair were considered pathognomonic for a lightning strike. The question arose as to whether Lichtenberg figures, for example, represented the finding that most often led to the correct diagnosis. Of the 270 lightning-struck victims from the case collection, 129 (47.8%) had singed body hair and 25 (9.3%) had Lichtenberg figures. A comparison of the frequency of the two reported findings, singed body hair versus Lichtenberg figures, has only been performed in the literature for case numbers below 40. This study is the first evaluation of a relatively large number of lethal accidents due to lightning. Singed body hair was reported more frequently in lightning-struck victims than Lichtenberg figures. This study showed that singed body hair is probably more diagnostically important than Lichtenberg figures.
Full-metal jacket mild steel core ammunition : a case report
(Lippincott, Williams & Wilkins, 2023-12) Blumenthal, Ryan; Rossouw, Servaas Hofmeyr; ryan.blumenthal@up.ac.za
The deceased was a 26-year-old man who was killed in a multiple shooting incident while sitting alone in his car. This individual was shot by multiple individuals, with different types of ammunition, from different angles. It is beyond the scope of this article to describe all the gunshot wounds. It is the intention of the authors to merely focus on the pathology of trauma of full-metal jacket ammunition with a penetrator (mild steel core in this presentation). The authors describe what was found at autopsy.
The added value of molecular-based diagnostics in the African forensic medical setting
(Clinics Cardive Publishing, 2022-09) Van Deventer, B.S.; Makhoba, Aubrey Musa; Du Toit-Prinsloo, L.; Van Niekerk, Chantal
Sudden unexpected infant death (SUDI) is reported to be an extraordinarily high burden in sub-Saharan Africa, with the incidence rate in South Africa among the highest in the world. It is common for the cause of many such infant deaths to remain unexplained even after a full medico-legal death investigation, and then to be categorised as a sudden unexplained infant death (SUID). Fortunately, advances in molecular- based diagnostics allow researchers to identify numerous underlying inherited cardiac arrhythmogenic disorders in many SUDI cases, with a predominance of variants identified in the SCN5A gene. Such cardiac arrhythmogenic-related sudden deaths generally present with no structural alterations of the heart that are macroscopically identifiable at autopsy, therefore highlighting the importance of post mortem genetic testing. We report on a significant genetic finding that was made on a SUDI case in which the cause was ascribed to an acute bacterial pneumonia but it was still subjected to post mortem genetic testing of the SCN5A gene. The literature shows that many SUDI cases diagnosed with inherited cardiac arrhythmogenic disorders have demonstrated a viral prodrome within days of their death. It is therefore not uncommon for these cardiac disorders in infants to be mistaken for flu, viral upper respiratory tract infection or pneumonia, and without the incorporation of post mortem genetic testing, any other contributory causes of these deaths are often disregarded. This study highlights the need for research reporting on the genetics of inherited cardiac disorders in Africa.
An atypical asphyxial death : a case study
(Lippincott Williams and Wilkins, 2023-09) Blumenthal, Ryan; Ferraris, Stefanie Claudia; ryan.blumenthal@up.ac.za
An atypical asphyxial death is presented. The deceased was found wrapped like a mummy with multiple layers of plastic and adhesive tape, lying face down on the floor of his home. The death scene was in the lounge area of a large, poorly-kempt, free-standing house. No obvious evidence of illicit drugs or other medications were identified. There was no pornographic material or other paraphernalia of a sexual nature in proximity to the body. According to the brother, the deceased had attempted similar incidents like this in the past, where someone was available to release him. Because of the similar behaviour in the past, the background psychiatric history, and statements from the girlfriend and relatives, the authors propose that this represents an atypical asphyxia death.
Practical tips to using formalin-fixed paraffin-embedded tissue archives for molecular diagnostics in a South African setting
(AOSIS, 2022-06-23) Van Deventer, Barbara Stroh; Du Toit-Prinsloo, L.; Van Niekerk, Chantal
BACKGROUND : Formalin-fixed paraffin-embedded (FFPE) tissue archives in hospitals, biobanks, and others offer a vast collection of extensive, readily available specimens for molecular testing. Unfortunately, the use of tissue samples for molecular diagnostic applications is challenging; thus, the forensic pathology FFPE tissue archives in Africa have been a largely unexploited genetic resource, with the usability of DNA obtainable from these samples being unknown. INTERVENTION : The study, conducted from January 2015 to August 2016, determined the usefulness of FFPE tissue as a reliable source of genetic material for successful post-mortem molecular applications and diagnostics. Formalin-fixed paraffin-embedded tissue samples were collected and archived from autopsies conducted over 13 years in the forensic medicine department of the University of Pretoria (Pretoria, South Africa). Deoxyribonucleic acid from FFPE tissue samples and control blood samples was amplified by high-resolution melt realtime polymerase chain reaction before sequencing. The procurement parameters and fixation times were compared with the quantity and quality of the extracted DNA and the efficiency of its subsequent molecular applications. LESSONS LEARNT : This study has shown that FFPE samples are still usable in molecular forensics, despite inadequate sample preparation, and offer immense value to forensic molecular diagnostics. RECOMMENDATIONS : FFPE samples fixed in formalin for more than 24 h should still be used in molecular diagnostics or research, as long as the primer design targets amplicons not exceeding 300 base pairs.
The “hypopigmented” bitemark : a clinical and histologic appraisal
(Springer, 2023-01) Robinson, Liam; Bunn, Belinda Kathleen; Blumenthal, Ryan; Bernitz, Herman; liam.robinson@up.ac.za
So-called “hypopigmented” bitemark patterns, commonly seen but not limited to dark skinned individuals, can be of value in forensic investigations. The process of aging bitemarks observed on skin is controversial and without guidelines. This report analyzes tissue obtained from the site of a hypopigmented bitemark using special histochemical stains for the identification of melanin pigment, and a panel of immunohistochemical markers to aid in the aging process. Histologic evaluation clearly showed that cellular changes in the hypopigmented area were indicative of wound healing that had taken place over a period of time. This validates the hypothesis that a hypopigmented bitemark is an indication of a wound inflicted some days previously. These findings have value in forensic investigations, particularly in cases of suspected long-term physical abuse.
Glass penetrating skull injury mimicking projectile injury
(Lippincott, Williams & Wilkins, 2022-06) Blumenthal, Ryan; ryan.blumenthal@up.ac.za
A 29-year-old man was involved in a motor vehicle accident as a driver in May 2021. According to the available history, his car overturned and hit a wall. Death was due to head injury. Diffuse brain injury was present. A small piece of glass penetrated the left occipital bone of the skull. What was remarkable was that this wound mimicked a projectile injury. Were it not for the small fragment of glass lodged within the central aspect of the bony wound defect, this wound could have been construed as that of a projectile injury.
Postmortem genetic testing in young individuals : what clinical medical practitioners need to know
(Health and Medical Publishing Group, 2022-12) Van Deventer, Barbara Stroh; Du Toit-Prinsloo, Lorraine; Van Niekerk, Chantal; u26376645@tuks.co.za
The death of a young person is most often a tragic occurrence, more so when this death was unexpected. Forensic pathologists are mandated to investigate such deaths, and there has been a strong move internationally towards genetic testing as an additional investigative tool. The aim of our article is to bring the advantage of implementing the so-called molecular autopsy in a local setting to the attention of medical practitioners. When a multidisciplinary approach is taken in cases of sudden unexpected death, the benefits to family members, and society as a whole, are irrefutable.
Cardiovascular deaths : what do the genes say?
(Health and Medical Publishing Group, 2022-12) Van Deventer, Barbara Stroh; Du Toit-Prinsloo, Lorraine; Van Niekerk, Chantal; u26376645@tuks.co.za
Cardiovascular diseases (CVDs) are ever-increasing, and as such are considered to be one of the most concerning public health burdens worldwide. They remain the leading cause of death across the world (~17.7 million deaths were reported in 2015), accounting for 31% of all global deaths.
Discrepancies between clinical diagnoses and autopsy findings : a comparative study conducted in South Africa
(Health and Medical Publishing Group, 2022-11) Joubert, Doret M.; Rossouw, Servaas Hofmeyr; Solomon, C.; Meyer, Pieter Willem Adriaan
BACKGROUND. The anatomical pathology autopsy serves several purposes, notably as a quality management tool for evaluation of accuracy in clinical diagnosis. Despite its value, for various reasons there has been an international decline in autopsies conducted. In the modern medical era, with all its advances in technology, diagnostic techniques and interventions, there is still a high discrepancy between clinical diagnoses and postmortem findings. OBJECTIVES. To establish the discrepancies between clinical diagnoses and postmortem findings in anatomical pathology autopsies. METHODS. A retrospective, descriptive study was conducted over the 4-year-period 2014 - 2017. The clinical diagnoses and postmortem findings of cases referred to the Department of Anatomical Pathology at the University of Pretoria, South Africa, were evaluated and compared using the modified Goldman criteria. RESULTS. A total of 288 cases qualified for the study and were evaluated. The gender distribution was 155 (53.8%) male and 133 (48.2%) female, with the majority of cases in the age group 19 - 60 years (mean 36.4). The majority of the cases were referred by internal medicine, followed by paediatrics. The most common cause of death in major missed diagnoses was pulmonary conditions. Of the cases, 115 (39.3%) had a major discrepancy and 62 (21.5%) a minor discrepancy. CONCLUSION. This study showed that there is still a high discrepancy between clinical diagnoses and postmortem findings, similar to studies conducted globally. The current COVID-19 pandemic may be a driver for revival of the anatomical pathology autopsy, and future studies are recommended to evaluate whether the decline can be reversed.
Traumatic diaphragmatic injuries at medicolegal autopsy : a 1-year prospective study
(Lippincott, Williams & Wilkins, 2022-12) Van Wyk, Charmaine; Hlaise, Keven Khazamula; Blumenthal, Ryan
INTRODUCTION : Traumatic diaphragmatic injuries (TDIs) are relatively rare. The forensic literature pertaining to TDIs consists mainly of case studies, suggesting little attention to these injuries during autopsies and research. MATERIALS AND METHODS : This prospective study was conducted at the Ga-Rankuwa Forensic Pathology Services mortuary over a 1-year period. We included all cases who had a full medicolegal autopsy, as prescribed by the relevant South African legislation (Inquest Act 58 of 1959). All diaphragms were examined by a forensic medical practitioner performing the autopsy. RESULTS : Nine hundred ninety-nine cases were analyzed; of these, 71 cases with TDIs were identified. The incidence of TDI was, therefore, determined to be 7.11%. A total of 60.56% involved the right hemidiaphragm, 19.72% the left hemidiaphragm, and 19.72% were present bilaterally. A total of 85.92% were present in men and 14.08% in women. Blunt force trauma comprised 33.80%, and penetrative trauma 61.97%. Most were associated with severe injuries. A total of 12.68% had organ herniation through the defects present. CONCLUSIONS : Our study revealed that TDIs were more common than initially reported. The right side was more often involved in our study than in other studies. Diaphragmatic injuries were observed in 21.46% of all penetrative trauma cases received in a year.
Pulmonary aspiration of brain matter in a motor vehicle fatality : a case study
(Lippincott, Williams & Wilkins, 2023-03) Weyers, Carmen Zenda; Makhoba, Musa Aubrey; Blumenthal, Ryan; carmen.weyers@up.ac.za
We present the case of an adult man who was involved in a motor vehicle accident as a driver. Histological examination of the lung tissue showed the presence of brain tissue within the lumens of the bronchi and bronchioles. Aspiration of brain matter is a rare phenomenon, with only 1 case described in the literature. The finding of brain tissue within the bronchi and terminal bronchioles supports the scenario of a period of agonal respiration with consequent cerebral aspiration. This article adds to the limited literature, distinguishing antemortem or agonal aspiration from postmortem passive movement.
Lightning metallization injury
(Lippincott, Williams & Wilkins, 2022-12) Blumenthal, Ryan; Nixon, Kenneth J.; Gomes, Chandima; Hunt, Hugh Gp; ryan.blumenthal@up.ac.za
We report the case of an unusual lightning-related phenomenon. A 41-year-old male construction worker sustained a direct lightning strike, at approximately 16:00 SAST, in mid-November 2021. Scene examination showed a large amount of mud, because of the rain, and remnants of torn-and-tattered clothing.
Double death electrocution in the bathtub
(Lippincott, Williams & Wilkins, 2022) Blumenthal, Ryan; Mabotja, Seduma Suzan; Soul, Bathabile; ryan.blumenthal@up.ac.za
We report the case of a 25‐year‐old woman and her 3‐year‐old son who were found dead in the bathtub because of electrocution. The case happened in August, which is winter, in South Africa. An electrical urn used to heat the bathwater was plugged into the mains and apparently fell into the water. The chrome taps contacted the shoulder of the woman and provided a pathway for the electrical current. Both mother and child died from electrocution, although the child showed signs of drowning. This case is unique in that it represents a double death due to electrocution in a bathtub.
An evaluation of the differences in paediatric skeletal trauma between fatal simple short falls and physical abuse blunt impact loads : an international multicentre pilot study
(Elsevier, 2021-06) Rowbotham, Samantha K.; Blumenthal, Ryan; Delabarde, Tania; Legrand, Laurence; Van der Walt, Elizabeth; Sutherland, Tom; Lockhat, Zarina I.; Arthurs, Owen J.
In cases where a deceased child exhibits trauma as a result of a physical abuse blunt impact load, a parent/caregiver may provide a simple short fall (SSF) as the justification for that trauma. The skeletal fractures remain difficult to differentiate between a SSF and physical abuse however, as both are the result of a blunt impact load, and are therefore biomechanically alike, and the rare nature of these fatalities means only anecdotal research has been available to validate such claims. The aim of this pilot study was to investigate if there may be differences in the skeletal fracture patterns and types resulting from SSFs compared with those resulting from physical abuse blunt impacts. Paediatric (<10 years) cases of fatal SSFs (≤1.5 m) and physical abuse were collected from the Victorian Institute of Forensic Medicine (Australia), Institut Médico-Légal de Paris (France), University of Pretoria (South Africa) and Great Ormond Street Hospital (England). For each case the intrinsic and extrinsic variables were recorded from medico-legal reports and skeletal trauma was documented using post-mortem computed tomography scans and/or skeletal surveys. Three SSFs and 18 physical abuse cases were identified. Of the SSF cases, two exhibited fractures; both of which were simple linear neurocranial fractures. Comparatively, 12 of the physical abuse cases exhibited fractures and these were distributed across the skeleton; 58% located only in the skull, 17% only in the post-cranial and 25% located in both. Skull fracture types were single linear, multiple linear and comminuted. This pilot study suggests, anecdotally, there may be differences in the fracture patterns and types between blunt impact loads resulting from a SSF and physical abuse. This data will form the foundation of the Registry of Paediatric Fatal Fractures (RPFF) which, with further multicentre contributions, would allow this finding to be validated.
Transdermal fentanyl death pact
(Lippincott, Williams & Wilkins, 2022-06) Blumenthal, Ryan; Roth, Lisa Barbara; ryan.blumenthal@up.ac.za
We report the case of a double suicide in an elderly couple, which occurred during COVID-19 lockdown. According to the son, this was a premeditated death pact, which was carefully planned. The parents had stockpiled fentanyl patches, which were prescribed for nonspecific neck pain management of the 76-year-old woman.
Death investigation and forensic medicine in South Africa : historical perspectives, status quo, and quo vadis?
(Sage, 2020-12) Saayman, Gert; gsaayman@up.ac.za
South Africa is burdened by both an exceptionally high crude death rate and a very high non-natural death rate. Efficient death investigation may greatly aid in identifying and addressing public health issues, while also being a prerequisite for the administration of justice. To improve the quality and consistency of death investigation in a country or region, it will help to have an understanding of relevant historical developments as well as the current sociopolitical, legislative, and organizational perspectives which may shape and underpin the forensic medical and scientific investigation of death. This review aims to provide the reader with some insights in this regard.

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