Can verbal autopsies be used on a national scale? Key findings and lessons from South Africa's national cause-of-death validation study.

BACKGROUND: Verbal autopsy (VA), though imperfect, serves as a vital tool to determine cause-of-death, particularly for out-of-facility deaths, but challenges persist in integrating VA into Civil Registration and Vital Statistics systems. OBJECTIVE: To describe the challenges and successes of collecting a national sample of verbal autopsy interviews in South Africa to obtain the cause of death profile in 2017/18. METHODS: We recruited next of kin from 27 randomly selected sub-districts (10.5%) across South Africa between September 2017 and April 2018. Trained fieldworkers conducted face-to-face interviews using the WHO2016 VA instrument, with physicians certifying underlying causes of death. Feasibility was evaluated based on response rates, participation, and data quality. RESULTS: Of the total 36,976 deaths registered, only 26% were identified during recruitment, with a 55% overall response rate for VA interviews. Physician-reviewed VA data were deemed of good quality for assigning underlying causes of death in 83% of cases. By comparing cause-specific mortality fractions, physician-reviewed VA identified 22.3% HIV/AIDS and InterVA-5 identified 18.5%, aligning with burden of disease estimates, while Statistics South Africa reported 4.9% HIV/AIDS. CONCLUSIONS: The study demonstrated the feasibility of using VA on a national scale, but immense challenges in identifying and recruiting next of kin highlight the importance of formalising VAs within the country's death notification system.

• Main findings: Next of kin of 9 730 decedents were approached at the time of registration of death and 55% consented to be approached later and agreed to do a VA interview by a trained field-worker; 83% of physician-reviewed VA data were considered high-quality for determining underlying causes and 22.3% of all the deaths were due to HIV/AIDS, much higher than the proportion reported in the national statistical office.• Added knowledge: Implementing the VA on a national scale was achievable but significant challenges in recruiting next of kin, emphasising a need to formalise VAs within the country's death notification system.• Global health impact for policy and action: Accurate cause-of-death data are crucial for policymakers to make informed decisions about the country's health system and could be supported by using VAs, particularly for the deaths that occur outside health facilities.

Injury mortality in South Africa: a 2009 and 2017 comparison to track progress to meeting sustainable development goal targets.

BACKGROUND: Injuries, often preventable, prompted urgent action within the United Nations' 2030 Agenda for Sustainable Development Goals (SDGs) to improve global health. South Africa (SA) has high rates of injury mortality, but accurate reporting of official national data is hindered by death misclassification. OBJECTIVE: Two nationally representative surveys for 2009 and 2017 are utilised to assess SA's progress towards SDG targets for violence and road traffic injuries, alongside changes in suicide and under-5 mortality rates for childhood injuries, and compare these estimates with those of the Global Burden of Disease for SA. METHODS: The surveys utilised multi-stage, stratified cluster sampling from eight provinces, with mortuaries as primary sampling units. Post-mortem files for non-natural deaths were reviewed, with additional data from the Western Cape. Age-standardised rates, 95% confidence intervals (CIs), and incidence rate ratios (IRRs) were calculated for manner of death rate comparisons and for age groups. RESULTS: The all-injury age-standardised mortality rate decreased significantly between 2009 and 2017. Homicide and transport remained the leading causes of injury deaths, with a significant 31% decrease in road traffic mortality (IRR = 0.69), from 36.1 to 25.0 per 100 000 population. CONCLUSIONS: Despite a reduction in SA's road traffic mortality rate, challenges to achieve targets related to young and novice drivers and male homicide persist. Achieving SA's injury mortality SDG targets requires comprehensive evaluations of programmes addressing road safety, violence reduction, and mental well-being. In the absence of reliable routine data, survey data allow to accurately assess the country's SDG progress through commitment to evidence-based policymaking.

Main findings The significant decrease in South Africa's injury mortality rates between 2009 and 2017 appears to largely be driven by the significant 31% decrease in road traffic mortality rates.Added knowledge The 2009 and 2017 survey comparison provides an enhanced understanding of the profile for injury-related deaths, compared to misclassified vital statistics data, to track progress towards reaching Sustainable Development Goals.Global health impact for policy and action The significant reduction in road traffic mortality across all age groups suggests South Africa is making progress towards Sustainable Development Goal Target 3.6 for road safety. However, reducing violence, suicide, and newborn and under-5 injury mortality requires more targeted interventions.

Child abuse and neglect-related murders in South Africa: a comparison of two national surveys in 2009 and 2017.

BACKGROUND: Population-based statistics on deaths from child abuse and neglect are only routinely available in countries that have reliable national statistics on child murder. For low-income and middle-income countries, relatively little is known about prevalence trends of child murder. South Africa is an exception, having conducted dedicated national studies on child murders for 2009 and 2017 to provide data on child murders overall and on child abuse and neglect-related murders. We aimed to compare child abuse and neglect-related murders in South Africa across two surveys to determine any change between 2009 and 2017. METHODS: We conducted two retrospective national mortuary-based surveys on murder of children aged 0-17 years for 2009 and 2017 from a proportionate random sample of medico-legal laboratories in South Africa. A sampling frame of medico-legal laboratories for each study year was prepared with stratification by medico-legal laboratory size. A minimum of 2 years after the crime was allowed before data collection to enable progression of the investigation process. Child abuse and neglect-related murders were identified using both medico-legal laboratory post-mortem autopsy reports and police data. To identify a child abuse and neglect-related murder, we primarily used the framework of abuse happening within the context of responsibility of care arrangements but broadened this to include all perpetrators and abuse identified from the data. We stratified age into 0-4, 5-9, 10-14, and 15-17 years and further stratified children younger than 5 years into early neonates (newborns killed within 6 days of birth), 7 days to 11 months, and 1-4 years. We calculated incidence rate ratios (IRR) with 95% CIs to compare rates between 2009 and 2017. FINDINGS: An estimated 458 (95% CI 377-539) children in 2009 and 213 (179-247) children in 2017 were murdered in circumstances of child abuse and neglect. The percentage of all child murders that were child abuse and neglect-related declined from 2009 to 2017 (458 [45·0%] of 1018 in 2009 vs 213 [25·0%] of 851 in 2017), with the overall age-standardised rate decreasing from 2·6 to 1·1 per 100 000 children aged 0-17 years (IRR 0·43 [95% CI 0·35-0·54]). Girls represented 276 (60·3%) of 458 murders in 2009, which declined to 96 (45·1%) of 213 murders in 2017, and boys represented 178 (38·9%) of 458 murders in 2009 and 109 (51·4%) of 213 murders in 2017. The decrease was statistically significant for girls in the 0-4 year (IRR 0·33 [0·22-0·49]) and 5-9 year (0·33 [0·15-0·73]) age groups and for boys in the 0-4 year age group (0·49 [0·33-0·71]). Among early neonates (within 6 days of birth), the decrease in child abuse and neglect-related murders was more pronounced among girls than among boys (IRR 0·33 [95% CI 0·19-0·56] vs 0·46 [0·28-0·77]). INTERPRETATION: Child abuse and neglect-related murders are common in South Africa but our study shows that they can be reduced. The high rate of these murders points to the need to continue research and monitoring to inform priority targeted interventions and to better understand the impact of child support policies. FUNDING: Ford Foundation and South African Medical Research Council.

A study protocol to characterise pathophysiological and molecular markers of rheumatic heart disease and degenerative aortic stenosis using multiparametric cardiovascular imaging and multiomics techniques.

INTRODUCTION: Rheumatic heart disease (RHD), degenerative aortic stenosis (AS), and congenital valve diseases are prevalent in sub-Saharan Africa. Many knowledge gaps remain in understanding disease mechanisms, stratifying phenotypes, and prognostication. Therefore, we aimed to characterise patients through clinical profiling, imaging, histology, and molecular biomarkers to improve our understanding of the pathophysiology, diagnosis, and prognosis of RHD and AS. METHODS: In this cross-sectional, case-controlled study, we plan to recruit RHD and AS patients and compare them to matched controls. Living participants will undergo clinical assessment, echocardiography, CMR and blood sampling for circulatory biomarker analyses. Tissue samples will be obtained from patients undergoing valve replacement, while healthy tissues will be obtained from cadavers. Immunohistology, proteomics, metabolomics, and transcriptome analyses will be used to analyse circulatory- and tissue-specific biomarkers. Univariate and multivariate statistical analyses will be used for hypothesis testing and identification of important biomarkers. In summary, this study aims to delineate the pathophysiology of RHD and degenerative AS using multiparametric CMR imaging. In addition to discover novel biomarkers and explore the pathomechanisms associated with RHD and AS through high-throughput profiling of the tissue and blood proteome and metabolome and provide a proof of concept of the suitability of using cadaveric tissues as controls for cardiovascular disease studies.

Who is killing South African men? A retrospective descriptive study of forensic and police investigations into male homicide.

Not much is known about the perpetrators of male homicide in South Africa, which has rates seven times the global average. For the country's first ever male homicide study we describe the epidemiology of perpetrators, their relationship with victims and victim profiles of men killed by male versus female perpetrators. We conducted a retrospective descriptive study of routine data collected through forensic and police investigations, calculating victim and perpetrator homicide rates by age, sex, race, external cause, employment status and setting, stratified by victim-perpetrator relationships. For perpetrators, we reported suspected drug and alcohol use, prior convictions, gang-involvement and homicide by multiple perpetrators. Perpetrators were acquaintances in 63% of 5594 cases in which a main perpetrator was identified. Sharp objects followed by guns were the main external causes of death. The highest rates were recorded in urban informal areas among unemployed men across all victim-perpetrator relationship types. Recreational settings including bars featured prominently. Homicides clustered around festive periods and weekends, both of which are associated with heavy episodic drinking. Perpetrator alcohol use was reported in 41% of homicides by family members and 50% by acquaintances. Other drug use was less common (9% overall). Of 379 men killed by female perpetrators, 60% were killed by intimate partners. Perpetrator alcohol use was reported in approximately half of female-on-male murders. Female firearm use was exclusively against intimate partners. No men were killed by male intimate partners. Violence prevention, which in South Africa has mainly focused on women and children, needs to be integrated into an inclusive approach. Profiling victims and perpetrators of male homicide is an important and necessary first step to challenge prevailing masculine social constructs that men are neither vulnerable to, nor the victims of, trauma and to identify groups at risk of victimisation that could benefit from specific interventions and policies.

Femicide, intimate partner femicide, and non-intimate partner femicide in South Africa: An analysis of 3 national surveys, 1999-2017.

BACKGROUND: In most countries, reliable national statistics on femicide, intimate partner femicide (IPF), and non-intimate partner femicide (NIPF) are not available. Surveys are required to collect robust data on this most extreme consequence of intimate partner violence (IPV). We analysed 3 national surveys to compare femicide, IPF, and NIPF from 1999 to 2017 using age-standardised rates (ASRs) and incidence rate ratios (IRRs). METHODS AND FINDINGS: We conducted 3 national mortuary-based retrospective surveys using weighted cluster designs from proportionate random samples of medicolegal laboratories. We included females 14 years and older who were identified as having been murdered in South Africa in 1999 (n = 3,793), 2009 (n = 2,363), and 2017 (n = 2,407). Further information on the murdered cases were collected from crime dockets during interviews with police investigating officers. Our findings show that South Africa had an IPF rate of 4.9/100,000 female population in 2017. All forms of femicide among women 14 years and older declined from 1999 to 2017. For IPF, the ASR was 9.5/100,000 in 1999. Between 1999 and 2009, the decline for NIPF was greater than for IPF (IRR for NIPF 0.47 (95% confidence interval (CI) 0.42 to 0.53) compared to IRR for IPF 0.69 (95% CI 0.63 to 0.77). Rates declined from 2009 to 2017 and did not differ by femicide type. The decline in IPF was initially larger for women aged 14 to 29, and after 2009, it was more pronounced for those aged 30 to 44 years. Study limitations include missing data from the police and having to use imputation to account for missing perpetrator data. CONCLUSIONS: In this study, we observed a reduction in femicide overall and different patterns of change in IPF compared to NIPF. The explanation for the reductions may be due to social and policy interventions aimed at reducing IPV overall, coupled with increased social and economic stability. Our study shows that gender-based violence is preventable even in high-prevalence settings, and evidence-based prevention efforts must be intensified globally. We also show the value of dedicated surveys in the absence of functional information systems.

South Africa's male homicide epidemic hiding in plain sight: Exploring sex differences and patterns in homicide risk in a retrospective descriptive study of postmortem investigations.

South Africa has an overall homicide rate six times the global average. Males are predominantly the victims and perpetrators, but little is known about the male victims. For the country's first ever study on male homicide we compared 2017 male and female victim profiles for selected covariates, against global average and previous estimates for 2009. We conducted a retrospective descriptive study of routine data collected through postmortem investigations, calculating age-standardised mortality rates for manner of death by age, sex and province and male-to-female incidence rate ratios with 95% confidence intervals. We then used generalised linear models and linear regression models to assess the association between sex and victim characteristics including age and mechanism of injury (guns, sharp and blunt force) within and between years. 87% of 19,477 homicides in 2017 were males, equating to seven male deaths for every female, with sharp force and firearm discharge being the most common cause of death. Rates were higher among males than females at all ages, and up to eight times higher for the age group 15-44 years. Provincial rates varied overall and by sex, with the highest comparative risk for men vs. women in the Western Cape Province (11.4 males for every 1 female). Male homicides peaked during December and were highest during weekends, underscoring the prominent role of alcohol as a risk factor. There is a massive, disproportionate and enduring homicide risk among South African men which highlights their relative neglect in the country's prevention and policy responses. Only through challenging the normative perception of male invulnerability do we begin to address the enormous burden of violence impacting men. There is an urgent need to address the insidious effect of such societal norms alongside implementing structural interventions to overcome the root causes of poverty, inequality and better control alcohol and firearms.

The shared genetic architecture of suicidal behaviour and psychiatric disorders: A genomic structural equation modelling study.

Background: Suicidal behaviour (SB) refers to behaviours, ranging from non-fatal suicidal behaviour, such as suicidal ideation and attempt, to completed suicide. Despite recent advancements in genomic technology and statistical methods, it is unclear to what extent the spectrum of suicidal behaviour is explained by shared genetic aetiology. Methods: We identified nine genome-wide association statistics of suicidal behaviour (sample sizes, n, ranging from 62,648 to 125,844), ten psychiatric traits [n up to 386,533] and collectively, nine summary datasets of anthropometric, behavioural and socioeconomic-related traits [n ranging from 58,610 to 941,280]. We calculated the genetic correlation among these traits and modelled this using genomic structural equation modelling, identified shared biological processes and pathways between suicidal behaviour and psychiatric disorders and evaluated potential causal associations using Mendelian randomisation. Results: Among populations of European ancestry, we observed strong positive genetic correlations between suicide ideation, attempt and self-harm (rg range, 0.71-1.09) and moderate to strong genetic correlations between suicidal behaviour traits and a range of psychiatric disorders, most notably, major depression disorder (rg = 0.86, p = 1.62 × 10-36). Multivariate analysis revealed a common factor structure for suicidal behaviour traits, major depression, attention deficit hyperactivity disorder (ADHD) and alcohol use disorder. The derived common factor explained 38.7% of the shared variance across the traits. We identified 2,951 genes and 98 sub-network hub genes associated with the common factor, including pathways associated with developmental biology, signal transduction and RNA degradation. We found suggestive evidence for the protective effects of higher household income level on suicide attempt [OR = 0.55 (0.44-0.70), p = 1.29 × 10-5] and while further investigation is needed, a nominal significant effect of smoking on suicide attempt [OR = 1.24 (1.04-1.44), p = 0.026]. Conclusion: Our findings provide evidence of shared aetiology between suicidal behaviour and psychiatric disorders and indicate potential common molecular mechanisms contributing to the overlapping pathophysiology. These findings provide a better understanding of the complex genetic architecture of suicidal behaviour and have implications for the prevention and treatment of suicidal behaviour.

Understanding the burden of unidentified bodies: a systematic review.

While human identification is a crucial aspect of medico-legal investigations, many individuals remain unidentified each year across the world. The burden of unidentified bodies is often referred to when motivating for improved methods of identification, and anatomical teaching, yet the actual burden is somewhat unclear. A systematic literature review was undertaken to identify articles that empirically investigate the number of unidentified bodies experienced. Despite the large number of articles returned, an alarmingly low number (24 articles) provided specific and empirical details on the number of unidentified bodies, demographics and trends thereof. It is possible that this lack of data is due to the variable definition of 'unidentified' bodies and the use of alternative terminology such as 'homelessness' or 'unclaimed' bodies. Nevertheless, the 24 articles provided data for 15 forensic facilities across ten countries of both developed and developing statuses. On average, developing countries experienced more than double (9.56%) the number of unidentified bodies when compared to developed nations (4.40%). While facilities were mandated under different legislations and infrastructures available varied greatly, the most common issue faced is the lack of standardised procedures for forensic human identification. Further to this, the need for investigative databases was highlighted. Through addressing the standardisation of identification procedures and terminology, alongside the appropriate utilisation of existing infrastructure and database creation, the number of unidentified bodies could be significantly reduced globally.

Healthcare Utilization 12 Months Prior to Fatal and Non-fatal Suicidal Behaviour in Cape Town, South Africa.

The purpose of this study was to characterize healthcare use for general care and mental health one year before suicidal behavior among individuals with fatal and non-fatal suicidal behavior (NFSB) in Cape Town, South Africa. We linked electronic health records of 484 participants from a case series of 93 completed suicides on whom forensic autopsies were performed at a mortuary in Cape Town, between August 2014 and January 2016; and 391 patients admitted to hospital following NFSB between June 2014 and March 2015, and between August 2015 and August 2017. Time from last healthcare visit to date of suicidal behavior (fatal or non-fatal) was calculated, and Kaplan Meier curves were used to compare the differences by psychiatric diagnoses and study group. Overall, 64.5% of completed suicides and 65.9% of NFSB patients sought general healthcare in the year before suicidal behavior. Most of these visits occurred at hospital outpatient clinics (40.8%) and primary healthcare facilities (31.3%). The prevalence of preexisting psychiatric diagnoses and the use of mental healthcare services was lower for individuals who completed suicide compared to NFSB patients. Common reasons for a healthcare visit among individuals who completed suicide were chronic disease and assault; and psychiatric illness (depression, bipolar, and/or substance use disorders), chronic disease and HIV among NFSB patients. A large proportion of individuals with fatal and NFSB interacted with the healthcare system before suicidal behavior. These findings suggest opportunities for suicide prevention at primary healthcare facilities, antiretroviral treatment centers and emergency departments.HIGHLIGHTSHealthcare access is common among individuals with fatal and NFSB in the year before suicidal behavior.The prevalence of mental disorder diagnoses is higher among NFSB patients than among individuals who completed suicide.A greater proportion of NFSB patients accessed mental healthcare services compared to individuals who completed suicide.

Postmortem computed tomography plus forensic autopsy for determining the cause of death in child fatalities.

BACKGROUND: Postmortem computed tomography (CT) and magnetic resonance imaging have been gradually introduced to forensic pathology centres over the past two decades, with varying results in comparison to autopsy. OBJECTIVE: The purpose of this study was to determine the accuracy of postmortem CT in determining a cause of death in children who died of unnatural causes. MATERIALS AND METHODS: This was a prospective recruitment of 30 children (< 18 years) who underwent postmortem CT and a forensic autopsy. A cause of death was independently assigned by two experienced paediatric radiologists and compared to that of the forensic autopsy. RESULTS: A correct cause of death was assigned by reviewers 1 and 2 in 70% (n = 21/30) and 67% (n = 20/30) of cases, respectively. For gunshot injuries and blunt force head injuries, there was 91% (n = 10/11) and 100% (n = 6/6) agreement between forensic autopsy and both reviewers, respectively. No cause of death could be assigned by reviewers 1 and 2 in 27% (n = 8) and 30% (n = 9) of cases, respectively. An incorrect cause of death was assigned by both reviewers in one case (3%). The Cohen Kappa level of agreement between the forensic autopsy and reviewers 1 and 2 was k = 0.624 (95% confidence interval [CI]: 0.45-0.80, P = 0) and k = 0.582 (95% CI 0.41-0.76, P = 0), respectively. There was near perfect agreement between reviewers 1 and 2 (k = 0.905) (95% CI 0.78-1.00, P = 0). CONCLUSION: Postmortem CT has good diagnostic accuracy for identifying a cause of death related to trauma, but it has poor accuracy for children dying from causes not associated with apparent physical injury.

A retrospective study of death scene investigation practices for sudden unexpected death of infants (SUDI) in Cape Town, South Africa.

A death scene investigation (DSI) forms an integral part of the inquiry into death, particularly for sudden unexpected death of infants (SUDI). Global guidelines exist for DSI, however, previous studies have shown that South Africa does not routinely perform DSI for SUDI cases, nor is there a standard protocol in this regard. This was largely attributed to the large burden of SUDI cases as well as the lack of resources, due to South Africa being a developing country. This study assessed DSI practices at one of the largest mortuaries in Cape Town (Salt River Mortuary) to assess the scope of these practices within a resource-constrained context. Data were collected by retrospectively reviewing medico-legal case files (n = 454) from SUDI cases investigated at Salt River Mortuary over a two-year period. The results showed that SUDI death scenes were visited in 59.2% of cases at Salt River Mortuary, with poor and inconsistent levels of documentation. Death scenes were never investigated in cases where the infant was pronounced dead on arrival at a medical facility. The findings support the need for a locally relevant approach to DSI, coupled with specialized training for staff. Based on the limited resources, this should focus on the training of staff using the available resources and accurate use of documentation.

Homicide pattern among adolescents: A national epidemiological study of child homicide in South Africa.

BACKGROUND: Large numbers of young people die yearly due to homicide, but little is known about homicide during adolescence. Research primarily focuses on youth violence among young men and masks important gender-related factors inherent in the adolescent age group. Although young women are less likely to be victims of homicide, violence against women is an important form of violence experienced during adolescence. In this paper, we describe the prevalence of and gender difference in adolescent homicide in South Africa in 2009. METHODS: We conducted a retrospective national mortuary-based study to identify all child homicides (boys and girls < 18 years) in 2009 in a proportionate sample of mortuaries. Victim, perpetrator and crime data were collected in three phases: cases were identified from the mortuary register, the autopsy report and from police interviews. In this paper we focus on the adolescent group, aged 10 to 17 years. FINDINGS: We identified 674 (95% CI: 520-823) adolescent homicides for 2009, with more male (520) than female (154) homicides. This gender disparity increased as children aged, with the male homicide rate 27.9/100 000 population (95% CI: 20.3-35.5), nearly 5 times the female rate (4.5:1) of 6.5/ 100 000 population (95% CI: 4.7-8.2) in older adolescents (15-17 year old). Adolescent males were significantly more likely (61.2%) to die in a public space compared to female adolescents (39.3%) but more adolescent females (48.4%) died at home compared to adolescent males (32.9%). Adolescent females (42.1%) were mainly killed by a family member or intimate partner while adolescent males were predominantly (58%) killed by an acquaintance. CONCLUSION: We found a distinct gender pattern for adolescent homicide in South Africa. This pattern appears to be driven by gender norms that support violence. South Africa requires an investment in developing evidence informed interventions to reduce violence.

Global trends in the extent of death scene investigation performed for sudden and unexpected death of infant (SUDI) cases: A systematic review.

Sudden unexpected death of infants (SUDI) is the rapid and unexpected death of an infant aged less than 1year old. These deaths are referred for a medico-legal investigation to establish cause of death. National and regional protocols for the investigation of SUDI cases have been established in some countries and these typically include a death scene investigation component. However, there is a paucity of literature detailing the nature and extent of death scene investigation protocols. A systematic review was conducted to review the scope of death scene investigation of SUDI cases worldwide. Relevant articles (n=74) were identified by searching four literature databases, three discipline-specific journals, as well as each article's reference list, until saturation was reached. Of the 16 countries represented by the included articles, seven made specific reference to the standardised protocol used, which included photography, interviews and/or scene re-enactments. The remaining 54 studies appeared to include a subset of these analyses during death scene investigation, which varied between countries, and between SUDI admissions. This may be attributed to the differing socio-economic standings of countries, and the resources available. Only four studies were from developing countries, three of which originated from South Africa. Overall, where a standardised death scene investigation was performed, it added value to the post-mortem investigation; as such, death scene investigation should be encouraged in SUDI investigation. To this end, protocols should be established nationally, and contain core analyses, which could be expanded depending on the needs and resources of the country.

Investigation into abandoned neonates admitted to Salt River Forensic Pathology Mortuary, Cape Town.

The high rates of abandoned neonatal remains admitted to Salt River Mortuary (SRM), Cape Town, and the dearth of literature published in South Africa prompted a retrospective assessment of these cases to describe the profile and assess the scope of the post-mortem investigation of abandoned neonates, as well as determine the prosecution rate of abandoned live births. Demographic details, scene information and post-mortem findings were obtained from medico-legal case files concerning non-viable fetuses, stillbirths and concealment of birth cases admitted to SRM between 1 January 2012 and 31 December 2016 (n=249). Despite the majority of the cases being natural deaths, the cause of death frequently remained 'undetermined' in these cases, often due to the presence of decomposition. Histological analyses were only performed in a small fraction of undetermined cases. Furthermore, the hypothesis that the prosecution rate of abandoned live births is extremely low was supported by this study, with only one case prosecuted in the 5-year period. For the remainder of the cases, the court status was given as either 'under investigation' (47.8%) or 'case closed' (47.8%). In the majority of the instances, the case was closed due to the unknown identity of the biological mother; however, DNA analyses were not performed in all of these cases. Overall, the data highlighted the need for the development and implementation of standard protocols, and recommendations were made for conducting the medico-legal investigation of abandoned neonates in a South African setting.

A systematic review exploring the relationship between infection and sudden unexpected death between 2000 and 2016: A forensic perspective.

Death due to infectious diseases is a major health concern worldwide. This is of particular concern in developing countries where poor-socio economic status and a lack of healthcare resources contribute to the high burden of disease. In some cases death due to infection can be acute and aggressive, and death may occur without a diagnosis whilst the person is still alive. These deaths may ultimately lead to a medico-legal autopsy being performed. There are various mechanisms by which sudden death due to infection may occur. In addition, there are many risk factors associated with sudden death due to infection, which differ between infants and older individuals. However, it is unclear which pathogens and risk factors are most frequently associated with sudden death due to infection. Therefore a systematic review of articles and case reports published between 1 January 2000 and 30 June 2016 was undertaken in order to (1) explore the relationship between pathogens and their causative role and (2) identify the relationship between predisposing and/or risk factors associated with sudden death due to infection. Major databases were searched and after critical appraisal 143 articles were identified. It was found that respiratory infections and deaths involving bacterial pathogens were most commonly associated with these deaths. In addition the most common risk factors in infants were exposure to tobacco smoke and co-sleeping. In adults the most common risk factors were co-morbid conditions and illnesses. This information aids in a better understanding of these deaths and highlights the need for more research in this field, particularly in developing countries.

Ethical considerations in forensic genetics research on tissue samples collected post-mortem in Cape Town, South Africa.

BACKGROUND: The use of tissue collected at a forensic post-mortem for forensic genetics research purposes remains of ethical concern as the process involves obtaining informed consent from grieving family members. Two forensic genetics research studies using tissue collected from a forensic post-mortem were recently initiated at our institution and were the first of their kind to be conducted in Cape Town, South Africa. MAIN BODY: This article discusses some of the ethical challenges that were encountered in these research projects. Among these challenges was the adaptation of research workflows to fit in with an exceptionally busy service delivery that is operating with limited resources. Whilst seeking guidance from the literature regarding research on deceased populations, it was noted that next of kin of decedents are not formally recognised as a vulnerable group in the existing ethical and legal frameworks in South Africa. The authors recommend that research in the forensic mortuary setting is approached using guidance for vulnerable groups, and the benefit to risk standard needs to be strongly justified. Lastly, when planning forensic genetics research, consideration must be given to the potential of uncovering incidental findings, funding to validate these findings and the feedback of results to family members; the latter of which is recommended to occur through a genetic counsellor. CONCLUSION: It is hoped that these experiences will contribute towards a formal framework for conducting forensic genetic research in medico-legal mortuaries in South Africa.

Sexual homicides in South Africa: A national cross-sectional epidemiological study of adult women and children.

METHODS: We conducted a retrospective national mortuary based study to identify all adult female homicides (18 years and older) and all child homicides (boys and girls < 18 years) in 2009 in a randomly selected, proportionate sample of mortuaries. Victim, perpetrator and crime data were collected in three processes: from the mortuary register, the autopsy report and from police with the identification of sexual homicides validated across the data collection processes. FINDINGS: Among the 2670 (95% CI: 2311-2979) adult women killed in 2009, 494 (95% CI: 406-574) were identified as sexual homicides which was 19.8% (95% CI: 17.6-22.0) of all adult female homicides and among 1277 (95% CI: 1091-1462) children killed in SA, sexual homicides were found in 104 (95% CI: 77-132) of the child homicides which was 8.7% (95% CI: 10.9-11.2%) of these murders. Strangulation was the most common cause of death for both children and adult females. A distinct age and sex pattern was found among children with only 1% boy child death identified as a sexual homicide and 92% of all the child sexual homicides were among girls. Strangulation was the most common manner of death among children (35.5%) and perpetrators were seldom strangers. However, no difference in the proportion of convictions between the sexual homicides and non-sexual homicides were found for both adult females and children. CONCLUSION: Rape homicide is not a rare event in South Africa, with one in five female homicides and nearly one in ten child homicides identified with an associated sexual crime. These high prevalences are amongst the highest levels reported in the literature with our study among the few reporting on the epidemiology of child sexual homicide. Reducing mortality is an important policy goal for South Africa and for the rest of the world and the prevention of female and child homicide is an important part of attaining this goal.