Case Report: Competitive causes of death: a case report of non-mutilated but fatal traumatic railway injury

Introduction

Trains are land transportation with many benefits deriving from their efficiency in transporting passengers and goods. This mode of transportation has been utilized widely in Indonesia, connecting provinces in Sumatra, Kalimantan, Sulawesi, and mostly in Java islands. However, its safety is concerning especially with the record number of railway-related accidents. Ministry of Transportation of the Republic of Indonesia reported that, from 2015 to 2020, the number of train accidents was 130 cases.¹ The train accidents that occurred over these five years caused multiple deaths and serious injuries. In 2015, an accident took the life of one person and caused three individuals to suffer serious injuries and 39 others minor injuries.¹ In 2016, the total number of victims was 97, with 43 people dead, 41 people severely injured, and 13 people minorly injured.¹ Furthermore, as many as 252 people were victims of train accidents in 2017, with 87 people dead, 79 people seriously injured, and 86 people lightly injured.¹ Meanwhile, in 2018, there was a train accident that resulted in four victims; three were seriously injured with one dead.¹ Records on train accidents found in 2019 showed 19 minorly injured individuals, and in 2020 there were no fatalities.¹ However, these numbers are expected to be underreported.

Traumatic injuries and disorders caused by railway accidents have medical and legal consequences, including for dead victims. The cause of death from railway-related injuries is clear in mutilated or decapitated bodies.² However, in patients with multiple fatal injuries, establishing the cause of death is challenging. Herein, we report the case of fatal pneumothorax and base-of-skull fractures as the competitive cause of death. In addition, we report our determination on the manner of death.

Case report

On Tuesday, 19 July 2022, at 00.24 West Indonesian Time (Coordinated Universal Time (UTC)+07:00), a Pertamina train bound for Surabaya-Malang crossed the Margorejo Shelter on Ahmad Yani Street, Surabaya, Indonesia. The train officers saw a man standing on the edge of the railway who was hit by the incoming train. After an examination and search at the crime scene, the victim was found to possess no identification documents (Figure 1a). The body was then identified at Dr. Soetomo General Academic Hospital by a forensic expert team. The external, internal, and additional investigations were conducted. The external examination suggested the presence of abrasions on the face, waist, and all four limbs (Figure 1b). Lacerations were found on the face and right earlobe. Open head fractures were also observable. The internal examination revealed the presence of lacerations on the liver, fourth and sixth right rib fractures, skull-base fractures, bleeding in the chest cavity, collapsed left lungs, and lower right and left lungs, and blood infiltration in the chest cavity wall muscles, and scalp muscles (Figure 1c–e). The patient’s nail was taken for further DNA examination.

Figure 1. Crime scene, external and internal examination and pneumothorax test of the victim.

(a) Photographed image of the crime scene with victim has been wrapped in a body bag before transported to Dr. Soetomo General Academic Hospital for autopsy. Identification documents were not found on the victim. External examination suggesting the presence of lacerations on the face and right earlobe and open head fractures (b). Internal examination suggesting the presence of lacerations to the liver fractures (c); on one to four left ribs, bleeding in the chest cavity, fractures on one to four left ribs, bleeding in the chest cavity, collapsed left lungs, and blood infiltration in the muscles chest cavity (d); and skull base fracture through the foramen magnum (e). Pneumothorax test on the chest and air embolism test on the heart (f-h) indicate the left chest was positive for pneumothorax but the heart was negative for air embolism.

A pneumothorax test was performed on the patient’s chest. After reflecting the front portion of the chest up to the midaxillary lines, water was poured into the angle between the subcutaneous tissue flap of skin with the scalpel held in the right hand, and the intercostal tissues below the water line were pierced toward the right side of the chest. The test was negative. The same test on the left chest was conducted using a 5 mL syringe filled with water after removing the plunger. Then the needle was pierced into the pleural space and bubbles were present, confirming a positive result of the pneumothorax test. An air embolism test on the heart was also performed by opening the pericardium and filling it with water. Once the heart was fully submerged in water, the right atrium and ventricle were incised. The result turned out to be negative because of the absence of bubbles observed after the incision. The photographed images of the pneumothorax test and air embolism test are presented in Figure 1f–h, respectively.

Based on the examination, the cause of death was determined to be blunt force trauma to the head, causing a fracture to the base of skull and aggravated by blunt force to the chest, resulting in suffocation.

Discussion

The patient herein was witnessed to be standing against the incoming train and hit by the train. The patient was found dead, with abrasions and lacerations all over the body and open head fractures. Most suicide cases have decapitation injuries because the individuals lay down on the railway to avoid the brake being pulled when they are seen by the train driver.³ However, the patient in this present case report did not suffer from decapitation, which is understandable since the patient was hit by the train while standing. The injury profile herein also had a distinct similarity with that obtained in victims who were killed crossing the rails.^3–7 The suspicion toward suicide became stronger as the patient did not have an identification card and the crash occurred at night. In a previous report, it was found that most suicide cases occur at night because the victim wants to avoid being seen and saved.⁶

At first, we suspected a traumatic pneumothorax as the cause of death because of a positive pneumothorax test on the left chest and collapsed left lungs. Air released from the ruptured alveoli could fill up the pleural cavity, which is normally empty, resulting in pain and suffocation to the victim.² A test on air embolism was carried out and turned out to be negative. Both a traumatic pneumothorax and air embolism could lead to death in a short amount of time.⁸ Further investigation at the base of the skull bones revealed the presence of fractures, located from the right front skull base, passing through the skull base hole, and to the left middle skull base bone. Therefore, the fracture of the skull base was decided as the cause of death. Skull fractures have been reported predominantly in victims who are hit by a train while walking.⁷ Fractures at the base of the skull have been reported as the cause of death in victims receiving a blunt force trauma.⁹ As a conclusion, the manner of death was determined to be unnatural in the form of suicide, and the cause of death was blunt force trauma, which resulted in a fracture of the base of skull.

Ethical approval

Not required.

Consent for publication

The authors have received written consent from the patient’s family and the Kepolisian Polrestabes Surabaya, Indonesia.