Comparison of Risk Factors and Preventable Causes of Unnatural Deaths from 1990 to 2017

Abstract

The aim of this study is to identify the possible risk factors and preventable causes of unnatural deaths. By doing so recommendations can be made to authorities to help create a safer environment for society. A retrospective, descriptive study was carried out and randomized samples were collected. A total of 772 medico-legal autopsy reports from 1990 to 2017 were divided into two groups for analysis and data collection. Group A consists of autopsy reports from 2016 to 2014 and Group B consists of autopsy reports from 1990 to 1996. Information such as age, sex, occupation, and brief facts about the case were collected. Nature of violence and cause of death were also studied. The trends between the two groups were then noted and compared and discussed. The commonest cause of death is homicidal in nature. The second highest nature of violence is accidental cases for example falling from trees, roofs, or brawling or falling due to old age. Firearms are the most commonly used weapons. The most likely to be at risk of unnatural death is a young, healthy male adult of age group of 21–30 and 31–40. Females of age group of 21–30 and 11–20 are more at risk.

1. Introduction

Over the past few decades, there has been a noticeable rise in crime and a corresponding rise in cases of unnatural deaths. In a study carried out in Karachi in 2009, out of 2090 medico-legal autopsies 98.7% were found to be unnatural deaths [1]. A death is considered unnatural if it is homicidal, suicidal, accidental, or due to some other violent or unexplained cause [2]. It is in the best interest of society to work toward reducing the number of medico-legal deaths. This will lessen not only the economic burden but also the psychological and emotional stress that results in depression and post-traumatic stress disorder [3]. Such circumstances reduce the overall productivity and mental health of a society. It is necessary to reduce deaths. A risk factor is anything that increases the likelihood to suffer harm. It may be sex, occupation, or even geographical location.

In a study for risk factors of unnatural deaths, fatal accidental intoxication was found to be associated with male gender, use of heroin, and use of cannabis. Death from intoxication/injury of undetermined intent was associated with heroin use as well as binge drinking of alcohol and previous psychiatric hospitalization. Death from suicide was associated with previous suicide attempts and sedative use [4].

The aim of this study is to identify possible risk factors and preventable causes of unnatural deaths. By doing so recommendations can be made to authorities to help create a safer environment for society.

2. Materials and methods

• Study type: A retrospective, descriptive study

• Sampling technique: Randomized samples were collected. A total of 772 medico-legal autopsy reports from 1990 to 2017 were divided into two groups for analysis and data collection. Group A consists of autopsy reports from 2016 to 2014 and Group B consists of autopsy reports from 1990 to 1996.

• Information like age, sex, occupation, and brief facts about the case was collected. Nature of violence and cause of death were also studied. The trends between the two groups were then noted and compared and discussed.

• Place of study: Conducted in Forensic Medicine department KEMU, Lahore, Pakistan.

• Duration of study: 5 months from March to June (2017)

• Inclusion and exclusion criteria: Severely decomposed bodies and cases where cause of death was unidentified were excluded

3. Results

Table 1 illustrates the age wise distribution that shows that most likely healthy young male adults are at risk to suffer death. For analysis, the data has been divided into two groups. Group A comprises of 665 cases from the year 2014–2016 and Group B comprises of 107 cases from 1990 to 1996. Group A shows that the highest number of unnatural deaths for males was in 2014 (210, 91.7%). However, the highest number of deaths for females was in 2016 (44, 18.6%). The ratio of male to female deaths is the same for Group B (4.35:1) and for the year 2016 in Group A highlighted in yellow in Table 1. It is interesting to note that two samples of data almost 20 years apart have presented with the same ratio and could provide basis for further study. The age group most likely to be affected for males is 21–30 with 2014 presenting with the most cases (57) followed by 2015 (43), 2016 (41), and group B (34). The second highest affected age group is 31–40. The most cases are presented in 2014 (51) followed by age group 41–50.

Group A							Group B
	2016 (236)		2015 (200)		2014 (229)		1990–1996 (107)
Range (years)	Female	Male	Female	Male	Female	Male	Female	Male
0–10	8	3	4	5	2	8	3	2
11–20	7	14	9	11	4	12	5	12
21–30	11	41	16	43	7	57	5	34
31–40	5	43	5	39	3	51	2	14
41–50	6	37	2	37	1	34	3	12
51–60	5	32	1	17	0	28	2	10
61–70	2	22	0	9	1	19	0	3
>70	0	0	1	1	1	1	0	0
Total	44 (18.6%)	192 (81.3%)	38 (19.0%)	162 (81.0%)	19; (8.3%)	210 (91.7%)	20; (18.6%)	87; (81.3%)

Table 1.

Age-wise distribution.

The trend seems to be similar for both Group A and B for males but the trend is different for females. For females, the age group most likely affected is also 21–30 but this time the highest number of cases is seen to be in 2015 (16) followed by 2016 (11), 2014 (7), and group B (5). It is followed by 11–20 as the second highest affected age group with 2015 of group A again presenting the most number of cases (9).

Table 2 illustrates the nature of violence in which homicide is the commonest for both sexes. The year with the highest number of cases for males is 2014 (92) followed by 2016 (88) and Group B (82). 2015 has the lowest number of cases (77) for males. Females present with the highest cases in 2016 (31) followed by 2015 (27), 2014 (18), and group B with 16 cases.

Group A							Group B
	2016 (236)		2015 (200)		2014 (229)		1990–1996 (107)
Type	Female	Male	Female	Male	Female	Male	Female	Male
Homicide	17	53	19	61	15	79	9	59
Suicide	0	0	0	0	0	0	0	0
Accidental	1	14	1	4	0	5	0	13
RTA	0	12	3	0	0	1	2	9
Industrial	0	0	0	0	0	0	0	1
Burn	6	6	1	4	0	0	5	0
Strangulation	7	3	3	8	3	7	0	0
Total	31	88	27	77	18	92	16	82

Table 2.

Nature of violence.

Line chart 1.

The highest number of homicidal cases is 79 in 2014 for males and 19 cases in 2015 for females. The lowest number of homicidal cases is 53 in 2016 for males and 9 cases in group B for females. The second highest nature of violence is accidental cases for example falling from trees and roofs or brawling or falling due to old age. The highest number of cases was present in 2016 (14) followed by group B (13) for males. RTA (road traffic accidents) is third commonest with the highest number in 2016 (12) followed by group B (9) for males. The trend seems similar to that seen in accidental cases. Strangulation is the fourth commonest with the highest number of cases being 8 in 2015 for males and 7 in 2016 for females. The trend for burn cases is erratic. Both males and females presented with equal number of cases (6) in 2016 but in 2015 the ratio for males to females is 4:1 and in Group B only 5 female burn cases were found. 2014 presented zero burn cases. Number of cases due to industrial causes and suicide was almost zero.

Table 3 illustrates the commonest mechanism of death is hemorrhagic vascular with the most number of cases being 75 for males in 2014 followed by Group B (69). For females, the highest is 16 in 2016 followed by 14 in 2015. However, there is only 1 case of hemorrhage in 2014 for females. The second most common mechanism is neurogenic/shock/coma. Both 2016 and group B have the highest cases for males (15). For females, the highest number of cases is 10 in 2015. Septicemia/infection is highly uncommon in Group A but is prominent with 10 cases for males in Group B. Asphyxia is more common in females in 2016 (7 cases) but more common in males in 2015 (8) and 2014 (7). In Group B, there are zero cases of deaths by asphyxia.

Group A							Group B
	2016 (236)		2015 (200)		2014 (229)		1990–1996 (107)
Type	Female	Male	Female	Male	Female	Male	Female	Male
Hemorrhagic/; Vascular	16	48	14	52	1	75	2	69
Neurogenic/; Shock/coma	0	15	10	9	2	9	8	15
Septicemia/; Infection	1	1	0	2	0	0	3	10
Asphyxia	7	3	3	8	3	7	0	0
Total	24	67	27	71	6	84	13	94

Table 3.

Mechanism of death.

Table 4 shows that firearms are the most commonly used weapons in 2014 (54 cases) and Group B (53 cases) followed by 29 cases in 2015 and 28 cases in 2016. The highest number of cases with blunt weapon/means used are in 2015 (46 cases) and 2014 (44). Compared to the other choice of weapons, sharp edge weapons are uncommon with the highest number of cases being only 17 in Group B and the lowest number of cases being 6 in 2014.

Table 4.

Nature of weapon.

In Table 5 in Group A, the organ with the highest rate of damage is the brain. 2015 presents with the highest number of cases 48 followed closely by 2014 with 47 cases and 2016 with 39 cases. But Group B has only 17 cases that involve the brain, while the organ most damaged is the lung with 40 cases followed by 2014 (30 cases), 2015 (16), and 2016 (18). For liver highest number of cases is 24 in Group B and 13 in Group A (2014). The second highest organ damaged in Group B is heart with 26 cases but the cases decrease in number in Group A with the highest number of cases being only 14 in 2014. Most number of cases involving intestines in Group B is 18. The number of cases involving kidneys decrease from Group B (10) to Group A (2016 with 4 cases).

Group A				Group B
	2016 (236)	2015 (200)	2014 (229)	1990–1996 (107)
Brain	39	48	47	17
Heart	8	5	14	26
Lungs	18	16	30	40
Liver	9	5	13	24
Diaphragm	1	3	6	12
Stomach	7	3	8	21
Intestines	12	4	12	18
Kidney	4	5	2	10

Table 5.

Organs and viscera involved.

Table 6 illustrates that deaths involving head injury alone are the highest in group A with 30 cases in 2016 followed by 2015 (22) and 2014 (20). In Group B deaths involving abdominal injury and bony fractures are more common with 20 cases each.

Group A				Group B
	2016 (236)	2015 (200)	2014 (229)	1990–1996 (107)
Chest injury	17	9	11	10
Abdominal injury	11	10	15	20
Head injury	30	22	20	13
Multiple injuries	12	8	10	10
Bony fractures	10	6	8	20
Limbs	2	4	2	0

Table 6.

Associated injuries.

Table 7 highlights that tuberculosis has been a major cause of death in 2016 with 45 cases and in 2014 with 33 cases. Chronic inflammatory lung disease is the second commonest cause with 35 cases in 2016 (Table 8).

Group A				Group B
	2016 (236)	2015 (200)	2014 (229)	1990–1996 (107)
T. B	45	29	35	4
COPD	22	23	30	0
CILD(lung)	35	34	35	3
CILD (liver)	12	8	14	0
Meningitis/ encephalitis /coronary disease	3	2	5	0

Table 7.

Natural deaths.

Group A				Group B
Geographical Locations	2016 (236)	2015 (200)	2014 (229)	1990–1996; (107)	Total
City Division	131	90	115	42	378
Civil Lines Division	52	35	44	23	155
Cantonment Division	33	30	29	15	107
Iqbal Town Division	10	24	15	14	68
Model Town Division	8	10	11	11	40
Sadar Division	10	11	15	2	38
Total	234	200	229	107	772

Table 8.

Geographical locations.

4. Discussion

The most likely to suffer from an unnatural death is a healthy young male adult. The age group with the most frequent deaths is 21–30 for both sexes with the second highest age group being 31–40 for males and 11–20 for females. For the highest age group, 21–30 for males, 2014 presented with the most cases (57) followed by 2015 (43), 2016 (41), and group B (1990–1996) showed 34 cases.

A study carried out in Peshawar, Pakistan studied a total of 3265 autopsies. 2839 were male and 426 were female showing a ratio of 6.66:1 [5]. In a study carried out in India in 2020, 10.3% of total deaths were unnatural and were greater in the population aged 10 to 45 years. The unnatural mortality rate was found to be 0.84 per 1000 among the male population and 0.49 per 1000 among the female population [6]. However, in another study in India in 2014, 74% of the victims of unnatural deaths were found to be adolescents and were 3 times more common than other age groups [7]. In a study in Shanghai, China in 2015, the male-to-female ratio of unnatural deaths was 2.02:1, and the average age was 40.9 [8]. These findings may probably reflect the more active role males have in society. Young men are more prone to imitate violent acts displayed on entertainment media or peer pressure to participate in criminal activities [9].

The commonest nature of violence as shown in Table 2 is homicide followed by strangulation, burn, accidental, and then RTA (road traffic accident) in Group A. The trend is similar in Group B, however, there are zero strangulation cases and accidental cases are the second commonest. The trend in homicidal cases as seen in Table 2 indicates that homicidal cases involving females are much less in number than males. This is similar to several other studies in Pakistan indicating that this may be significant [10, 11, 12]. The slope rises from right to left, which shows that female homicidal cases have increased in the last 30 years but it is the opposite case for males. In addition, there is a sharp increase in male homicidal cases in 2014 (79 cases).

A study conducted in South Africa noted the frequency of death from homicide and factors associated with homicide death. The study took place between 2000 and 2008 and reported 536 homicide-related deaths. The overall homicide rate was 66 deaths per 100, 000 person-years of observation [13]. A study in the Netherlands among 2130 homeless persons found the most frequent cause of death to be unnatural deaths (26%). Of these suicide and homicide were responsible for 50% [14]. Another study in Ontario, Canada investigated homicide cases over a period of 1999 to 2012 and found that victims were mostly young males of 15–29 years. The trend of homicides followed an upward increase and the overall rate was found to be 3.85 per 100,000 population [15].

A study by Kleeman and Fischer in 1994 examined a group of homicide victims over the years 1978–1988 to determine the causes of their injuries. Out of 251 cases, they found that 51.4% of homicide victims had injuries due to blunt trauma, 31.9% were due to sharp trauma and 29.5% were from strangulation. Shootings were found to be less common (18.7%) and other types of traumas were around 4.0%. The most common victims of blunt force trauma and sharp trauma were male, 51.9% and 33.6%, respectively. Females demonstrated injuries due to blunt trauma (50.8%) as well as strangulation (47.5%). Women were commonly murdered by the aggressor’s bare hands within the setting of conflicts in relationships. In 36.7% of all cases, injuries were caused by a combination of aggressive traumas [16].

In yet another study from Western Norway, cases of 196 homicide victims from 1985 to 2009 were investigated. The median age of the victims was 35 years, including both genders. 113 of the victims were male and 83 were female. Most of the victims were killed by blunt trauma, sharp injury, or gunshot wound. The body region most often injured was found to be the head area. Female victims were more likely to be killed by strangulation than male victims [17].

An analysis of female homicide victims during a 10-year period was carried out in Taiwan. Among 220 adult victims, 114 were killed by intimate partners and 106 were killed by non-intimate partner offenders. The most common site of injuries was the neck and the upper limbs, respectively. The most common causes of death were strangulation and sharp force injury. The area of heart was injured more frequently in victims attacked by intimate partners than by other types of offenders [18].

The male-to-female ratio for burn cases in 2016 is 1:1 but in Group B, the only burn cases were of 5 females. This may be due to the honor killings that are now less common because of a more educated society. Burn victims accounted for 10.79% of medico-legal deaths studied in Kanpur, India over a period of 1 year [19]. In a study in Cairo, Egypt over a five-year period (2006–2010), around 3981 cases of autopsies were investigated. Out of these cases, 106 (2.66%) were found to be burn victims [20].

A total of 109 cases of death due to fatal burns were studied in Mumbai, India from 2014 to 2015. Cases were studied with respect to marital status, alleged history of dowry death, manner of death, history of psychiatric illness, chronic diseases, previous suicidal attempts, etc. Out of the 109 cases, females accounted for 92 cases (84.4%). Accidental deaths were 71 in number (65.14%). Sixty-seven cases (61.47%) of death due to septicemia and 42 (38.53%) died due to shock [18].

In yet another study in Nagpur, India, 384 cases of medicolegal deaths were studied. It was found that deaths due to burning accounted for 21.6% of all cases. Female victims were seen more than males (74.2%) with a male–female ratio equal to 1:2.9. Most of the victims of burn deaths were between 11 and 40 years with peak at 21–30 years (47.1%). The commonest manner of death by burning was accidental in nature (75%) by suicidal and homicidal burning [21].

Table 3 illustrates that the most common mechanism of death is hemorrhagic/vascular followed by neurogenic shock/coma and then asphyxia while septicemia is the least common in both groups. The results of Tables 2 and 3 can be explained after looking at Table 4, which presents the choice of weapon. Firearm is the most frequently used weapon in both group B and 2016 of group A, whereas blunt weapon/means is the more common choice of weapon in 2015 and 2014 of group A. This reflects that ownership of firearms in society is not kept under proper supervision and may be in the hands of unlicensed owners. Theft and robberies are carried out more and more with firearms [22]. In 2016, 251,000 people died from firearm injuries around the world [23]. Blunt weapons and means are now more common than they were 30 years ago in group B. This may be due to the increase in violence and crime rates and gangs. In 2020, around 1,313,105 violent crimes were reported in the United States, which was an increase from the year 2019 when 1,250,393 violent crimes were reported [24].

Table 5 reveals that in the last 30 years, the most likely damaged organ has changed from lungs to the brain. Also, cases involving the heart, liver, stomach, intestines, and diaphragm have decreased but cases involving kidneys have increased in number. Table 6 of associated injuries helps to shed light on the findings of Table 5. These cases are where the major injury related to death is abdominal injury alone or head injury alone or chest injury alone. The cases of head injuries (20 cases) in group B have shown an increase of almost 50% that is up to 72 cases in Group A. Abdominal injuries on the other hand occurred more frequently in group B. Cases involving chest injuries are second most frequently occurring.

There is plenty of data in similar studies carried out in Pakistan that corresponds to our findings that head injuries are most common in homicidal cases followed by Chest injuries. A study carried out in Karachi in 2012 found that head injuries were at 44.2% and the second commonest were chest injuries at 28.5% [25]. In Brazil from 2015 to 2018, head injuries were identified in 168 homicide victims and accounted for 68.3%. The study also found an association between the presence of head injuries and number of injuries (p < 0.05) [26].

Table 7 titled natural deaths showcases interesting results. Out of 772 medico-legal autopsies, there were 113 cases (14.6%) of tuberculosis [TB] and 75(9.7%) cases of chronic inflammatory lung disease [CILD]. This displays that TB and other respiratory diseases are risk factors. The incidence of increase in Tb may be largely due to the rise in population that the economy cannot support resulting in cramped living spaces. In 2019, approximately 1.21 million HIV-negative patients died of TB [27]. According to World Health Organization (WHO), the association between TB and poverty is mediated by overcrowding, poorly ventilated housing, malnutrition, smoking, stress, social deprivation, and poor social capital [28]. For effective control of spread of TB, there is need for development of an effective surveillance system, improved speed of diagnoses of cases, improved healthcare in rural areas, and increased provision of healthcare staff and laboratory facilities [29].

According to data collected in the United States in 2020, the top 3 causes of preventable deaths were poisoning, motor vehicles, and falls accounting for 86% of all preventable causes [30]. According to a study carried out in Finland, accidental deaths and suicide mortality rates of men were 2–13 and 2–3 times those of women, respectively. Deaths due to homicide were less prevalent among either sex [31]. In 2010, a study in Germany reported a total of 14,441 unnatural deaths (suicide, traffic accidents, and homicide). Of those, 10,021 subjects (69.4%) committed suicide, 3942 (27.3%) died in traffic accidents, and 478 (3.3%) were murdered. Suicide death rates were 3 times higher in men than women [32]. A Suicide appears to be a risk factor for unnatural deaths and may be prevented by awareness of mental health issues. Seminars may be held on mental health awareness and pamphlets can be published with information on recognizing suicidal tendencies in people prone to anxiety and depression. A study in the United Kingdom investigated the prevalence of suicide ideation in patients with psoriasis. Patients with psoriasis were found to have an increased risk of depression, anxiety, and suicidality. The study took place from 1987 to 2002 and estimated 10, 400 diagnoses of depression, 7100 diagnoses of anxiety, and 350 diagnoses of suicidality and were attributable to psoriasis annually [33].

Study of risk factors and preventable causes of unnatural death allows for making of health policies, which may help to prevent rise in cases of unnatural deaths. A death is considered unnatural if it is homicidal, suicidal, accidental, or due to some other violent or unexplained cause. The preventable causes include homicide, suicide, accidents, etc. Homicide death is death at the hands of one human being to another human being. Accidental deaths are described as deaths occurred due to accidents. Suicide is death voluntarily or intentionally by a human being to his or herself. Some unnatural deaths may have an undetermined cause that cannot be found by autopsy [34]. A study conducted in Germany aimed to identify frequency and causes of unnatural deaths among infants, 339 cases were investigated over a three-year period (from 1998 to 2001). The frequency of unnatural deaths was found to be 5.0% (n = 17). The causes of death included head injury (n = 7), where n = number of cases, suffocation (n = 5), poisoning (n = 2), neglect (n = 2), and septicemia due to aspiration of a foreign body (n = 1) [35].

Homicide, Suicide, and accidental deaths or undetermined causes of unnatural deaths may decrease the mental health of a society. A study carried out in Denmark, in 2001 by Hiroeh and Appleby, showed that 25% of 17,892 psychiatric patients died from unnatural causes. Patients with schizophrenia or other diagnosed mental disorders were shown to be at increased risk for death by homicide. Alcoholics and drug users were at increase for death by both homicide and accidents, and risk of death by suicide was highest among drug users [36].

Suggestions can be made to health policymakers to decrease such causes. Homicide can be prevented by improved law enforcement and surveillance of areas where homicide deaths are more likely to occur. In a study, in 2018 in United States, data on 54,170 deaths was collected and 24% were found to be due to homicide. Increased security around areas where homicidal deaths are more likely to occur will help to decrease the frequency of homicidal deaths [37].

According to a study carried out in the United States by Post and Mason in 2021, surveillance on gun usage and gun policy may decrease homicide due to firearms. The results of the study showed that the Federal Assault Weapons Ban (FAWB) (1994–2004) had a positive impact in discouraging firearms. The FAWB prevented 11 public mass shootings during the decade it was in effect. Linear regression analysis of the data showed that continued implementation of the FAWB would have prevented 30 public shootings and saved the lives of 339 people and 1139 injured people [38].

Deaths from unnatural causes are preventable. Identifying risk factors may allow health policymakers a greater depth of understanding of the needs of the population when designing public health guidelines. Appropriate safety measures can be put into effect more easily. Previous literature on the subject is sparse. The aim of this study is to address this gap and identify the risk factors associated with unnatural deaths in a third-world country. In this study, factors such as male gender, younger age, and geographical areas with higher crime rates have been identified to increase the likelihood of unnatural death. In a study by Wilson and Gaugrhan in 2019, factors associated with unnatural mortality in patients with serious mental disorders were studied. Patients with serious mental disorders who died from unnatural causes were likely to be of younger age, male or have a psychiatric diagnosis, or have been recently discharged from a psychiatric hospital [39].

The importance of reducing deaths related to unnatural causes is many folds. Firstly, the economic burden on society can be reduced and psychological stress of families suffering from loss of loved ones can be reduced. Such emotional distress leads to mental distress furthering the risk of mental health disorders. The overall productivity of society can be reduced if these stressors remain prevalent. A study analyzing pattern of deaths in Dhaka Medical College, India found 1725 unnatural deaths out of 1772 total deaths. The frequency of causes was 69% road traffic accidents, 12% homicide, 8% suicide, and 3% natural. Burn, electrocution, and others causes comprised the rest [40].

Identifying factors and their reduction can help to increase the socioeconomic wealth and leads to improved well-being of a society. A healthy society can lead to improvement in functioning and can lead to further success such as in economy and infrastructure. A study in Lucknow India from 2008 to 2012 identified the causes and epidemiological aspects of unnatural deaths in the elderly. There were 3165 male victims and 1240 female victims. Unnatural deaths were higher in rural (64%) than in urban (37%) areas. Accidental deaths were the most common manner of unnatural deaths (59%), followed by suicidal deaths (34%) and homicidal deaths (7%) [41]. Rural areas where socioeconomic wealth is low show higher risk of unnatural deaths indicating that improvement in socioeconomic wealth of society will improve well-being and will likely decrease the risk of unnatural deaths.

This present study aims to fill the gap in current research on preventable causes of unnatural deaths and their associated risk factors. Further research on this topic can benefit society by helping to further supplement understanding of the areas that need improvement and can, therefore, decrease the likelihood of unnatural deaths.

5. Conclusion

The most likely to be at risk of unnatural death is a young, healthy male adult of age group of 21–30 and 31–40. Females of age group of 21–30 and 11–20 are more at risk. The most common nature of violence is homicide followed by strangulation, burn, accidental, and then RTA (road traffic accident). The commonest mechanism of death is hemorrhagic/vascular followed by neurogenic shock/coma and then asphyxia while septicemia is the least common. Firearm is the most frequently used weapon followed by blunt means/weapon and Sharp-edge weapon. Frequently associated injury is head injury followed by chest injury. TB, CILD, and other respiratory diseases are likely to be preventable causes.