Egyptian Journal of Forensic Sciences (2016) 6, 381–387

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Egyptian Journal of Forensic Sciences

journal homepage: http://www.journals.elsevier.com/egyptian-journal-of-forensic-sciences

Spectrum of unnatural deaths associated with

positive toxicology findings in Eastern Province,
KSA: An autopsy based study
Sahar Y. Issa a,b,*, Mohammed El Dossary c, M. Abdel Salam c,
Maha K. Al-Mazroua b, Mostafa A. Hamd d, M. Kharoshah c
a
Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine – Alexandria University, Egypt
b
Regional Poison Control Center, MOH, Dammam, Saudi Arabia
c
Forensic Medicine, MOH, Dammam, Saudi Arabia
d
Forensic Medicine, MOH, Al-Madinah Al-Munawarah, Saudi Arabia

Received 6 November 2015; revised 10 May 2016; accepted 11 May 2016

Available online 27 May 2016

KEYWORDS Abstract Background: Mortality statistics are crucial for monitoring changes in death rates,
Autopsy; demographics and causes. The importance of autopsy performance and result documentation for
Unnatural deaths; mortality statistics has been referred to and debated over a long period in many places all over
Saudi; the world.
Poisoning; Objective: To determine the spectrum of unnatural deaths, focusing on toxicological findings in
Toxicology respect to gender susceptibility, inhabitant nationality, manners and causes of death, and weaponry
over a period of five years in the Eastern Province, Saudi Arabia.
Methods: The unnatural deaths whether suicidal, homicidal or, accidental fatalities in the period
from 2009 to 2013 in the Eastern Province, Saudi Arabia were retrospectively studied from autopsy
reports.
Results: Of the 1335 cases examined in the Dammam Forensic Center over five years, 220 unnatural
fatalities were positive for alcohol and poisons. All positive cases were investigated retrospectively by
the Forensic Medical Authority, Eastern Province in the five years period starting from 2009 till
2013. Toxicological results in the examined samples were obtained for all studied cases. The subjects
were chiefly males (90.9%), most of the cases were in the young age group aging between 21 and
30 years of age (30.5%). Accidental causes significantly predominated (61.8%) over suicidal and
homicidal causes (20.5%, and 10.9% respectively). Most of the cases were Saudi (45%), followed
by Indian nationals (25.5%).
Conclusion: In conclusion, this study highlights key findings of demographic differences in unnatural
deaths in the Eastern Province, Saudi Arabia.
Ó 2016 The International Association of Law and Forensic Sciences (IALFS). Production and hosting by
Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).

* Corresponding author at: Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine – Alexandria University, Egypt.
E-mail address: sahar_issa71@yahoo.com (S.Y. Issa).
Peer review under responsibility of The International Association of Law and Forensic Sciences (IALFS).
http://dx.doi.org/10.1016/j.ejfs.2016.05.005
2090-536X Ó 2016 The International Association of Law and Forensic Sciences (IALFS). Production and hosting by Elsevier B.V.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
382
1. Introduction
Official mortality rates are used to monitor trends, compare
causes, manners, and rates across regions, and assess risk fac-
tors. More than five million deaths occur annually, with inju-
ries and violence accounting for 10% of worldwide mortality.
Violence-related deaths are 7.1% more than the number of
fatalities that result from infectious diseases combined. Fur-
thermore, most of the leading causes for fatalities in people
aged between 15 and 29 years are injury-related. These injuries
result from acts of violence against oneself or others, road traf-
fic crashes, burns, drowning, falls, and poisonings, among
other causes.1–3
Internationally, governments, public and private partners
are increasingly attentive of the stresses that violence and inju-
ries place on humanities. In reaction, they are reinforcing data
collection schemes, improving services for victims and sur-
vivors, and increasing preventive measures that can reduce suf-
fering and save lives.4–6
Autopsy remains the most applicable medical tool of inves-
tigation used for observing the failure of the medical care
offered to the deceased, or to exclude the aspect of medical
negligence of the caring team and to see the role of violence,
if any.7
There is no precise registry based statistical data on unnat-
ural deaths in most of the countries world. Universally, homi-
cides represent approximately 1 million deaths, while suicide
leads to at least 1.1 million deaths annually. Approximately
1.7 million road traffic accident fatalities occur globally each
year as reported by the WHO.2 91% of the world’s deaths
due to road traffic accidents occurs in the low and middle
income countries.8 Poisoning deaths account for more than
60% of all undetermined deaths nationwide.9 Many studies
revealed that a proportion of undetermined deaths are proba-
bly unreported suicidal attempts, and suggested that the actual
reported suicide rates are underestimated by about 10–30%.10
Suicide may be seen in every community, both in ordinary
individuals responding to stressful life circumstances, or in
patients with severe mental disorders.11 Suicide is still a very
controversial matter, for being one of the main reasons for
death in recent years.12,13
Antisocial and criminal behavior is known to increase
among alcoholics.14It is of great importance to note that mea-
suring trends in alcoholics and alcohol-related violent prob-
lems is essentially challenging, and this relates to the
unreliability of data in most of alcohol related violent
behaviors.15
The aim of this study was to determine the spectrum of
unnatural deaths, focusing on toxicological findings in studied
cases regarding; gender susceptibility, inhabitant nationality,
manners and causes of death, and weaponry over a period of
five years in the Eastern Province, Saudi Arabia.
2. Methods
Of the 1335 cases examined in the Dammam Forensic Center
over five years (2009–2013), 220 unnatural fatalities were pos-
itive for alcohol and poisons.
Cases of apparently natural causes and cases of infanticide,
and maternal deaths were excluded from the study. The dead
S.Y. Issa et al.
bodies were examined in a definite prearranged order namely;
clothes and, external body examination, followed by autopsy
performance to find out the cause, manner, time since death,
and the weapon used, if any. Suspected tissues and body fluids
were collected and submitted for thorough toxicological anal-
ysis. Deceased’s sex, cause or manner of death, in addition to
the region from where the bodies were brought, and year of
incidence were reported. 10–15 ml of peripheral blood – being
the most reliable specimen for toxicological testing – was with-
drawn from the femoral vein in the thigh, the iliac vein, acces-
sible from the body cavity during internal examination, or
from the subclavian vein in the chest. 10–15 ml of urine were
collected with a syringe, through a simple incision allowing
visualization of the bladder. Vitreous was collected with a
hypodermic syringe by inserting the needle into each eye. Com-
prehensive examination of the collected samples was done for
all collected samples using the following protocol: blood and
urine samples of each subject were screened for ethanol and,
drugs of abuse (amphetamine, barbiturates, benzodiazepine,
cannabis, cocaine, and opiates) using fluorescence polarization
immunoassay (FPIA) principle on ARCHITECT system
c4000, model i1000 SR by Abbott laboratories. Using gas
chromatography – head space GC ultra-model
K0C33B730000000, Milano, Italy, all samples were analysed
for all volatiles including ethanol. Extraction and analysis by
gas chromatography-mass spectrometer GC-MS-QP2010,
Shimadzu for weakly acidic and neutral drugs, was then
performed. This included acetaminophen, non-steroidal
anti-inflammatory drugs, barbiturates, phenytoin, and
carbamazepine. Finally extraction and analysis by the same
GC–MS for alkaloid and basic drugs, including most common
centrally acting therapeutic drugs was done with the exception
of those checked for in weakly acidic and neutral extract. This
included antidepressants, stimulants, narcotics, antihistamines,
decongestants, muscle relaxants, anticonvulsants, organic
poisons, and antipsychotics. Finally analysis for detection of
carbon monoxide, or other specific tests which were specially
requested or suggested by the circumstances of the death were
done. Ethanol analysis was performed by static headspace
analysis.
2.1. Analysis of ethanol
As the limits for ethanol might be low, thus, a three – point cal-
ibration curve covering the ethanol concentration range
between 0.01 mg/dl and 10 mg/dl was constructed. Ethanol
standards, quality control samples and internal standards (n-
propanol, 10 mg/dl) were prepared in distilled water from
HPLC grade solvents. A resolution mixture of ethanol, n-
propanol, acetaldehyde, methanol and acetone were prepared
in distilled water from HPLC grade solvents at a concentration
of 100 mg/dl each.
2.2. Headspace procedure
The samples were placed in 20 ml headspace vials by adding
1.0 ml of samples, standards or quality control samples and
1 ml of internal standard. The samples were sealed using crimp
top vial caps with septa and were placed in the headspace rack.
Operation parameters are given in (Table 1).
Unnatural deaths associated with positive toxicology findings 383

Table 1 Parameters of head-space chromatography. 3. Results

Parameter Temperature
Figs. 1 and 2 revealed that the males (N = 200, 90.9%) pre-
Initial temp 45 °C vailed over females (N = 20, 9.1%), and the Saudi nationals
Max temp 350 °C
(N = 99, 45%) prevailed over non-Saudi cases. The highest
Ram 1 initial temperature 90 °C
incidence of non-Saudi cases was among Indians (N = 56,
Inlet temperature 230 °C
MS transfer line 250 °C 25.5%).
Ion source 220 °C The highest number of cases (N = 67, 30.5%) was detected
Syringe temperature 60 °C among victims in the age group (21–30 years), followed by the
age group (31–40 years), with a total number of 54 (24.5%)
Parameter Time
(Fig. 3). 56 (25.5%) of the cases in the dominant age group
Hold time 00.00 min were males, and 11 (5%) were females, with dominance of
Prep run timeout 99.00 min Non-Saudi nationals (34, 15.5%) (Table 2). The highest num-
Equilibrium time 00.50 min ber of unnatural female deaths was seen in this dominant age
Ram 1 hold time 01.00 min
group (Table 2).
Prep run timeout 99.00 min
Equilibrium time 00.50 min
The eastern region of Saudi Arabia is a vast area comprised
Gas saver time 03.00 min of many cities. The highest number of fatalities (N = 71,
32.3%) were encountered in Dammam which is the largest city
Parameter Volume in the Eastern Province of Saudi Arabia (Fig. 4).
Sample volume 01.00 ml Poisoning comprised the highest number of cases as the
cause of death (N = 72, 32.7%) (Table 3). 12.3% (N = 27)
of the poisoning cases was due to carbon monoxide.

2.3. Gas chromatography analysis

Distribuon of cases by Gender
The quantitative analysis of ethanol and its separation from [CATEGO
other low-molecular volatiles was done with a TRACETM ultra RY
gas chromatograph. NAME]
9.1%

2.4. Capillary gas chromatography/mass spectrometry analysis

(GC/MS)

The quantitative analysis of ethanol and its separation from

other low-molecular volatiles was done with a TRACETM ultra
gas chromatograph. Injections were made in the split mode. [CATEGO
RY
The column temperature program was isothermal at 90 °C. NAME]
Helium was used as the carrier gas. The injector and transfer 90.9%
line temperatures were 230 °C and the split ratio was 10:1 with
each sample lot, a calibration curve, a blank (distilled water) Figure 1 Distribution of cases as regards gender.
and quality control samples were run. The resolution mixture
was first run in a scan mode in the mass range of m/z 20 to m/z
120 to identify the compounds and subsequently the mixture
Distribution of cases by nationalities
was run in a SIM mode for the samples. The methods were lin-
ear in the concentration range used. Saudi
Blood and urine samples were analyzed for ethyl glu- 2% 2% 1%
Indian
curonide and ethyl sulphate (EtG and EtS) by liquid chro-
2% 7% Pakistani
matography tandem mass spectrometry using the 3%
N=99,
methodology described by Helander et al.,16 and only cases 6% Nepali
45%
with EtG levels P0.5 lg/mL (positive cut-off for EtG), and 6% Filipino
EtS P0.1 lg ng/mL (positive cut-off for EtS) were included
N=56, Sirilanki
in the study. 25.5%
Bangladeshi

2.5. Statistical analysis Indonesian

Sudanese
All the data obtained for the investigated cases were submitted Others
to statistical evaluation by SPSS program, version 22 and the
results were compared with similar studies. Figure 2 Distribution of cases as regards nationalities.
384 S.Y. Issa et al.

Distribution of cases by age groups Table 3 Distribution of cases by cause of death.

80
30.7% Cause of death Frequency Percent
70
60 24.5% 23.6% Poisoning 72 32.7
Frequency

Type N %
50
Carbon monoxide poisoning 27 12.3
40
DOA overdose 25 11.3
30
7.7% Pharmaceutical & pesticide 20 9.1
20 poisoning
4.1% 2.7% 3.2% 3.6%
10 Hanging 24 10.9
0 Road traffic accidents (RTA) 21 9.5
Age groups
Undetermined 20 9.1
0-10 11--20 21-30 31-40 41-50 51-60 61-70 >70 Burn 14 6.3
Firearm injury 13 6
Figure 3 Distribution of cases as regards age groups. Strangulation 13 6
Stab wound 9 4.1
Drowning 9 4.1
Falling from height 9 4.1
Head Injury 8 3.6
Cut throat 6 2.7
Traumatic asphyxia 2 0.9
Table 2 Distribution of cases by age group versus gender & Total 220 100.0
nationality.
Age groups Gender Nationality Total
Male Female Saudi Non-Saudi The second leading cause of death in the poisoning group was
due to overdose of drugs of abuse as seen in 25 of the cases
0–10 Count 8 1 9 0 9
(11.3%), followed by pharmaceutical and pesticide poisoning
% of total 3.6% 0.5% 4.1% 0.0% 4.1%
11–20 Count 4 2 6 0 6
(N = 20, 9.1%). Hanging as the cause of death accounted
% of total 1.8% 0.9% 2.7% 0.0% 2.7% for 10.9% (N = 24) of the cases, followed by road traffic acci-
21–30 Count 56 11 33 34 67 dents (21, 9.5%).
% of total 25.5% 5.0% 15.0% 15.5% 30.5% As regards detailed toxicological findings, 94 (42.7%) of the
31–40 Count 51 3 18 36 54 studied cases revealed ethanol in their analytical results, fol-
% of total 23.2% 1.4% 8.2% 16.4% 24.5% lowed by carbon monoxide (27, 12.3%), amphetamine (25,
41–50 Count 49 3 19 33 52 11.3%), cannabis (19, 8.6%), morphine (17, 7.7%) and heroin
% of total 22.3% 1.4% 8.6% 15.0% 23.6% (12, 5.4%) (Fig. 5).
51–60 Count 17 0 7 10 17 Ethanol was the sole toxicological finding in 26 (27.7%)
% of total 7.7% 0.0% 3.2% 4.5% 7.7%
cases, but was cofounding with other compounds in 68
61–70 Count 7 0 3 4 7
% of total 3.2% 0.0% 1.4% 1.8% 3.2%
(72.3%) of the positive 94 ethanol cases (Table 4).
>70 Count 8 0 4 4 8 Accidental manner of death was observed in 136 cases
% of total 3.6% 0.0% 1.8% 1.8% 3.6% (61.8%), followed by suicidal, homicidal and undetermined
Total Count 200 20 99 121 220 manners consecutively (Fig. 6), while the highest number of
% of total 90.9% 9.1% 45.0% 55.0% 100% the cases, was during the year 2013 (54, 25%), followed by
the year 2010 (53, 24%) (Fig. 7). Deaths due to most common

Distribution of cases by Region Toxicological findings in studied cases

Tramadol Methanol Acetaminophen
Alqareya 0.5%
Ras Tanorah Alolya Codeine Hydrogen0.9% 0.9%
Hafr El Baten Tarot Ibuprofen
1.4% 0.9% 0.9% Abqaiq 1.4% Sulphide
Aluminium Ephedrine Carbamate 0.5%
2.3% 0.5% 1.4%
Safwa Khafji phosphide 0.5% Pescides
Organophosphat Acetone 0.5%
Sihat 1.8% 1.4% 0.9%
e Pescides 1.4%
3.6% 3.2%
Naireyah
5% Di-acetyl
Dammam Morphine-Heroin
Dhahran 32.3% 5.4%
6.4% Morphine Ethyl Alcohol
7.7% 42.7%
Qatif Cannabis
9.1% 8.6%

Jubail Amphetamine Carbon

Khobar
11.3% monoxide
15.9% 18.6%
12.3%

Figure 4 Distribution of cases by region. Figure 5 Distribution of cases by toxicological findings.

Unnatural deaths associated with positive toxicology findings 385

12
Table 4 Distribution of ethanol positive cases by nationality,
and co-occurrence of other toxicological findings. 10
Nationality Toxicological results Total
8
Ethanol with other Ethanol
drugs alone
6
Saudi Count 8 18 26
% of 8.5% 19.2% 27.7% 4
total
Non- Count 58 10 68 2
Saudi % of 61.7% 10.6% 72.3%
total 0
Total Count 66 28 94 2009 2010 2011 2012 2013
% of 70.2% 29.8% 100.0%
total CO DOA Pharmaceucal & pescides

Figure 8 Deaths due to most common causes of poisoning

versus the studied year.
Distribuon of cases by manner
of death
6.8% ing from negligence or deliberate omission of some person. It
involves deaths encountered due to accidents or disasters as
10.9%
well.7 Detection of toxic substances plays a significant role in
Accidental
any forensic investigation. It is essential to reveal whether or
Suicidal
not the deceased was under the influence of ethanol or other
20.5% Homicidal
61.8% substances of abuse at the moment of an accident or criminal
Undetermined offence.17,18
Postmortem toxicology testing is an important ancillary of
the forensic autopsy. Intentional violent drug-related deaths
Figure 6 Distribution of cases as regards manner of death. are a major percentage of any forensic pathologist or medical
examiner’s workload. Poisoning, including ethanol, prescrip-
tion and illicit drugs, is considered the second leading cause
Frequency of studied cases per of fatal injuries.19 In line with many other studies, poisoning
60 was the most frequent leading cause of death.3,20,21
year
Usually, investigation of deaths includes investigation of
50 the death or crime scene noting the presence and types of all
54, 25% drugs, reviewing medical records, performing autopsy exami-
40 nation, followed by testing of collected postmortem fluids
2009 and tissues for qualitative and quantitative analysis of drugs
53, 24% and chemicals. Less frequently, an external examination of
30 2010
42, 19% the body with collection of postmortem samples for toxicology
2011
20 44, 20% testing instead of a complete autopsy is performed. Toxicology
2012 test results are interpreted in conjunction with autopsy findings
27, 12% and circumstantial evidences of death scene.22
10 2013
Suicide is one of the commonest leading causes of death
worldwide. Many have considered suicide to be an innately
0
violent act. Except for few neurobiological researches much
2009 2010 2011 2012 2013
of the investigation on the interrelationship of suicide and vio-
Figure 7 Frequency of studied cases per each year of the study. lence has focused on personality traits and psychiatric abnor-
malities related to self-reported harm and aggression, and it
is terrifying to account for alcohol abuse in surveys of the pos-
causes of poisoning versus the studied year are presented in sible role of ethanol in violence ending into suicide or homi-
Fig. 8, with the highest number of poisoning due to carbon cide.23,24 In accordance with other studies ethanol was the
monoxide inhalation, drugs of abuse and pharmaceuticals or most frequently detected poison either solely or together with
pesticide exposures recorded in the years 2012, 2011 and other drugs.25–27
2013 consecutively. Ethanol was the most commonly detected Males (N = 200, 90.9%) prevailed over females (N = 20,
substance in accidental, suicidal and homicidal deaths (Fig. 9). 9.1%) in the current study of unnatural fatalities. This obser-
vation is in accordance with other authors’ findings.28,29 This
4. Discussion might be attributed to more work stresses, activities, move-
ments, as well as increased incidence of exposure to external
Unnatural deaths entail fatalities caused due to criminal intent environment and contacts with other members of society.
of an offender to oneself or to others, as well as deaths result- Greater physical strength, more rapid anger, egoism,
386 S.Y. Issa et al.

Leading poisons detected versus manner of death

25 45.00%
40.00%
20 35.00%
30.00%
15
25.00%
20.00%
10
15.00%
5 10.00%
5.00%
0 0.00%

Accidental Suicidal Homicidal undetermined Total

Figure 9 Leading poisons detected versus manner of death in studied cases.

mind-set for vengeance are other reasons which lastly lead him
to be a victim or assailant.30
The present study revealed that the highest number of cases
(N = 67, 30.5%) was detected among victims in the age group
21–30 years, followed by age group 31–40 years, which was
similar to other relevant studies.31–33 Dammam, the largest
and most populous city in the Eastern Province, Saudi Arabia,
has dominance of immigrant workers from Southeast Asia,
mainly Indians, which explains the higher percentage of Indian
victims (56, 25.5%).34
In accordance with our results hanging was found to be the
second leading cause of death following poisoning in unnatural
fatalities as in India,35 but in many other countries, including
Japan and Germany it was the chief manner of unnatural
deaths.36,37
Ethanol was solely detected in only 27.7% of the ethanol
positive cases, while in 72.3% of the cases alcohol was detected
together with other drugs or chemicals, which is in accordance
with other studies.25–27 The actual underlying cause of death in
these cases is not ethanol or drug alone but the additive central
nervous system depression with concurrent use of both of them
leading to fatal overdose and death. This finding is in accor-
dance with other studies stating that the use of drugs with alco-
hol is usually associated with lethal poisoning.38
The highest number of unnatural deaths, was during the
year 2013 (54, 25%), followed by the year 2010 (53, 24%),
which is still markedly less than other countries.34,35 This
low number of unnatural fatalities can be ascribed to religious
factors, as well as relatively better, and strict law and order
condition in Saudi Arabia. Better intra personal and familial
bonds, behaviour and harmonious relationship amongst the
communities in this country are also important contributing
factors.31,36 This impression is further strengthened when it
is observed that the accidental causes in our study predomi-
nated the manners of unnatural deaths, and the percentage
of homicidal deaths is only 10.9% in comparison to what
has been reported by the other researchers which show a
higher rate of homicidal deaths.37,38
5. Conclusions
It is concluded that the precise statistical mortality database
for unnatural deaths may provide an enormous support for
the effect of different factors on aggressive behaviour, human
health and mortality. Poisoning deaths pose a distinctive diffi-
culty in defining the intent of death to medical examiners and
coroners. Violence is attributed to a variety of fatal outcomes
and it is critical to examine demographically which groups are
most affected. Such data will consequently help to better tailor
preventive efforts. Our findings call for an instant mandatory
regular testing program to thoroughly demographically and
toxicologically interpret findings in all postmortem settings
of unnatural fatalities.
Funding
None.
Conflict of interest
None declared.
Ethical approval
Necessary ethical approval was obtained from the institute
ethics committee.
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