Introduction
Medico-legal autopsy is actually the core of forensic medicine. It assists in determining the cause and mode of death, particularly in cases of sudden death or in situations where there is no doctor available [1,2]. In situations where people are brought dead to the hospital, meaning no signs of life whatsoever and declared dead immediately, it becomes even more important. These are referred to as Brought-in-dead (BID) cases. It provides concrete evidence from the body, you know, anatomical and pathological details [3,4]. This evidence is vital for the diagnosis of death, crime investigation, and even mortality rate compilation. In such circumstances, medico-legal autopsy is absolutely essential for the reconstruction of the circumstances of death and whether it occurred due to natural disease or external causes [5,6].
However, despite all these positive changes that have occurred in the ways we are able to diagnose and treat diseases, a lot of people in India still find themselves dying away from any real hospital or clinic. The reasons for this are quite obvious, actually. Things such as not having enough medical facilities around or emergency services that are not really well-organized before you get to a hospital. And then there are also the large disparities in terms of money and class, and sometimes people wait too long or go to the wrong place first. It all adds up to this problem [7,8]. In the case of BID cases, the burden they put on things shows more than what happens to one person. It shows larger issues in terms of how healthcare is provided for everyone, and how emergencies are handled in general. I think that BID is an important tool for determining whether public health is being provided for in the way that it should, although perhaps not everything is revealed there [9].
From the forensic perspective, BID deaths are linked to some diagnostic difficulties. The absence of prior clinical evaluation, the unavailability of medical history, and the unrecorded information regarding treatment pose difficulties in the application of clinico-pathological correlation [10]. In the absence of such information, the determination of cause and manner of death is largely dependent on the meticulous autopsy examination, along with circumstantial information. This creates a huge task for the forensic pathologist to make the correct interpretation and certification [11].
The cause of death is described as the disease, injury, or condition that directly caused death, while the manner of death is classified based on the circumstances into natural, accidental, suicidal, homicidal, or undetermined [12]. Proper classification is not only important for the administration of justice but also for civil and insurance litigation and the compilation of national mortality statistics [13]. Incorrect or uncertain death certification may result in legal controversies and may also impair the quality of health statistics, thus hampering the surveillance of epidemiological trends and health planning [13-15].
Research carried out in different parts of India has shown that natural causes form the predominant group of BID cases, and cardiovascular and respiratory diseases are the most frequent causes of death [16-18]. Nevertheless, the distribution of causes and mode of death is affected by a number of factors, including urbanization, socioeconomic status, environmental exposure, and accessibility of healthcare. Major cities like Delhi receive a substantial influx of migrants and transients, many of whom may not have regular access to healthcare, thus increasing the chances of sudden deaths in public or strange places [19,20].
Despite the significant medico-legal and public health implications of brought-in-dead cases, detailed epidemiological analyses from major urban centers in India remain limited. The present study was therefore undertaken to examine the demographic characteristics, cause and manner of death, seasonal trends, and place of occurrence among BID cases subjected to medico-legal autopsy at a tertiary care institution in national capital. The findings aim to provide scientifically robust data to support forensic practice, strengthen mortality surveillance, and inform evidence-based public health policy and preventive strategies.
Materials and Methods
This prospective epidemiological study was done in the Department of Forensic Medicine and Toxicology, at a tertiary care hospital in national capital, over a period of eighteen months from May 2023 to October 2024. This study had prior approval from the Institutional Ethics Committee, as per established ethical standards.
Inclusion and exclusion criteria
All BID cases aged 18 years and above who underwent comprehensive medico-legal autopsy were included. BID cases below 18 years of age as well as cases that were beyond medico-legal analysis due to advanced decomposition were excluded from the study since these circumstances may affect the accuracy of diagnosis or interpretation of autopsy result.
The information was collected from police inquiries, medical files in the hospital, circumstance evidence, as well as comprehensive post-mortem examination details. The analyses for toxins in the body and histo-pathological examination were also done when necessary to support the diagnostic results for the pathologies in order to verify the cause of death.
Statistical analysis
The data obtained was entered and analyzed using the Statistical Package for Social Sciences version 20.0. Descriptive statistics were employed to analyze the frequencies and percentages. Chi-square statistical tests were conducted to establish associations between categorical variables. A p-value of less than 0.05 established the significance of the associations according to the fundamental requirements of epidemiology and biostatistics.
Results
Among the 200 brought-in-dead cases that were analyzed, 180 (90%) were male and 20 (10%) were female, showing a clear male predominance with a male: female ratio of 9:1. The highest number of deceased was found in the productive age group, and the peak rate was recorded between 38 and 47 for age (Table 1).
The seasonal analysis established that the highest numbers of mortality rates were recorded during the winter season, accounting for over 50% of the total mortality rates. The major places of death were public places such as the areas along the railways, shelters. Railway Station was one of the major contributors.
| Variable | Category | Frequency (n) | Percentage (%) |
| Age group (years) | 18–27 | 24 | 12.0 |
| 28–37 | 47 | 23.5 | |
| 38–47 | 52 | 26.0 | |
| 48–57 | 34 | 17.0 | |
| 58–67 | 25 | 12.5 | |
| 68–77 | 13 | 6.5 | |
| 78–87 | 3 | 1.5 | |
| 88–97 | 2 | 1.0 | |
| Sex | Male | 180 | 90.0 |
| Female | 20 | 10.0 | |
| 200 | 100.0 |
| Manner of Death | Number of Cases | Percentage (%) |
| Natural | 128 | 64.0 |
| Accidental | 30 | 15.0 |
| Suicidal | 13 | 6.5 |
| Homicidal | 1 | 0.5 |
| Undetermined | 28 | 14.0 |
| Total | 200 | 100.0 |
Natural deaths comprised the largest percentage at 64%, followed by accidental deaths at 15%, suicidal deaths at 6.5%, and homicidal deaths at 0.5%. In 14% of the deaths, the manner of death was undetermined because of inconclusive results of circumstantial or investigation evidence. Analysis showed a statistically significant relationship between gender and manner of death, with males dominating accidental and suicidal deaths (Table 2).
Regarding natural deaths, pneumonitis proved to be the main cause of death followed by coronary artery disease. The remaining causes of such deaths were due to septicemia, tuberculosis, liver disease, and intracerebral hemorrhage. Deaths due to accidents were mainly from road traffic accidents and falls. Suicidal deaths were mostly from hangings and poisons
| Cause of Death | Female n (%) | Male n (%) | Total n (%) |
| Aortic stenosis | 0 (0.0) | 1 (0.5) | 1 (0.5) |
| Blunt force trauma | 0 (0.0) | 1 (0.5) | 1 (0.5) |
| Chronic liver disease | 0 (0.0) | 3 (1.5) | 3 (1.5) |
| Coronary artery disease | 1 (5.0) | 32 (17.8) | 33 (16.5) |
| Cranio-cerebral damage | 0 (0.0) | 6 (3.3) | 6 (3.0) |
| Fall from height | 0 (0.0) | 1 (0.5) | 1 (0.5) |
| Hemorrhagic shock | 0 (0.0) | 10 (5.6) | 10 (5.0) |
| Hemorrhagic shock (stab injury) | 1 (5.0) | 0 (0.0) | 1 (0.5) |
| Hanging | 3 (15.0) | 9 (5.0) | 12 (6.0) |
| Head injury | 0 (0.0) | 3 (1.7) | 3 (1.5) |
| Liver abscess | 0 (0.0) | 2 (1.1) | 2 (1.0) |
| Liver cirrhosis | 0 (0.0) | 2 (1.1) | 2 (1.0) |
| Liver failure | 0 (0.0) | 1 (0.6) | 1 (0.5) |
| Myocardial infarction | 0 (0.0) | 1 (0.6) | 1 (0.5) |
| Pending | 5 (25.0) | 25 (13.9) | 30 (15.0) |
| Peritonitis | 0 (0.0) | 1 (0.6) | 1 (0.5) |
| Pneumonitis | 5 (25.0) | 52 (28.9) | 57 (28.5) |
| Poisoning | 1 (5.0) | 1 (0.6) | 2 (1.0) |
| Pulmonary oedema | 0 (0.0) | 5 (2.8) | 5 (2.5) |
| Pulmonary tuberculosis | 1 (5.0) | 8 (4.4) | 9 (4.5) |
| Sepsis | 0 (0.0) | 1 (0.6) | 1 (0.5) |
| Septic shock | 1 (5.0) | 2 (1.1) | 3 (1.5) |
| Septicemia | 1 (5.0) | 6 (3.3) | 7 (3.5) |
| Shock | 0 (0.0) | 1 (0.6) | 1 (0.5) |
| Transection injury | 1 (5.0) | 6 (3.3) | 7 (3.5) |
| Total | 20 (100.0) | 180 (100.0) | 200 (100.0) |
A total of 200 medico-legal autopsy cases were studied. Pneumonitis was found to be the leading cause of death, accounting for 57 cases (28.5%), followed by coronary artery disease in 33 cases (16.5%). Pending cause of death was found to be 30 cases (15.0%), which represent the cases pending chemical analysis or further investigation. Hanging was found in 12 cases (6.0%), followed by hemorrhagic shock in 10 cases (5.0%). Male predominance was found in almost all causes of death, representing the overall gender distribution of the study population (90% males). Female deaths were relatively few and were mostly seen in pneumonitis, hanging, and pending investigations. The gender-wise distribution of causes of death is given in Table 3. There were a few cases that were pending or unknown, accounting for 30 cases (15%). This highlights the need for better forensic techniques to provide greater certainty regarding the cause and manner of death.
Discussion
The present study provides valuable insights into the epidemiological pattern of brought-in-dead (BID) cases in the metropolitan population. The preponderance of males, as observed in the present study, has been supported by the existing literature and can be explained by greater occupational exposure, psychosocial factors, migration, and risk-taking behavior among males [21-23]. The preponderance of natural deaths establishes the important role of undiagnosed and undertreated medical conditions in the population. Pneumonitis was established as the leading cause of death, which could be explained by the delay in seeking medical care, close living conditions, environmental pollution, and vulnerability to the disease during the winter season [24,25]. The high incidence of coronary artery disease also establishes the important role of non-communicable diseases in urban India, a situation that has been well established in the epidemiological literature of cardiovascular diseases [26,27]. Accidental deaths were also found to be largely among males, which highlights the existing gaps in road safety and occupational health care for the urban population. Even though the number of suicidal deaths was smaller, their importance cannot be ignored. The fact that deaths occur largely during the colder months of the year gives further strength to the existing literature that low temperatures are a contributing factor to the exacerbation of respiratory and cardiovascular diseases, thus leading to increased winter mortality rates. The fact that deaths also occur in public places further highlights the plight of migrant populations, homeless people, and the socially isolated who are often left outside the formal healthcare and social support systems. From the forensic perspective, BID deaths still pose a challenge in the aspect of diagnosis due to the absence of antemortem medical and clinical records [34,35]. In this kind of situation, a medico-legal autopsy examination with toxicological and histopathological examination still forms the basis of the diagnosis of the cause and manner of death [34,35]. The findings of the autopsy examination not only aid in the certification of individual deaths but also have significant importance in mortality surveillance and the formulation of preventive public health measures [36].
In earlier studies based on autopsies, the significance of forensic analysis in understanding patterns of fatal injuries has been emphasized. Yadav et al. have established a strong correlation between histopathological changes and modes of death in cases of burn deaths, as well as their relation to survival times [37]. Similarly, Singh et al. have established that the pattern and extent of extracranial and intracranial hemorrhages in fatal head injuries are significantly influenced by trauma dynamics and safety standards [38]. Other studies have also established that the severity of collision is a decisive factor in determining the severity of cranio-cerebral injuries in road traffic accidents. Collectively, these studies emphasize the significance of detailed postmortem analysis in establishing the cause of death, injury mechanisms, and medico-legal liability [39].
Conclusion
The current study makes it clear that the major proportion of BID deaths in an urban tertiary care hospital is due to natural causes, and the major contributors to such deaths are respiratory and cardiovascular diseases. The gender and age groups that are most commonly affected are males in the economically productive age group, and the factors that affect mortality rates are seasonality and geographic location. Improving access to early healthcare and emergency care services is a step in the right direction to prevent deaths.
Declarations
Ethical Statement
The current study has been performed after taking clearance from the Institutional Ethics Committee of the institute with Ref Number: LHMC/IEC/2023/PG Thesis/38; Date: 06/05/2023. This current study has been based on medico-legal autopsy cases brought dead to our hospitals and does not include any direct interaction with living subjects.
All the procedures were conducted after adhering to institutional ethical standards and the principles embodied in the Declaration of Helsinki. The confidentiality of individual identity and medico-legal details was maintained rigorously throughout the study. The data was used for strictly academic and research needs, and no identifying details of the deceased were revealed throughout the process.
Funding statement
Authors declare that this research received no funding from any external source.
Conflict of Interest
The authors declare that there is no conflict of interest regarding the publication of this article.