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

Background: Railway-related accidents can cause severe injuries, and, most of the time, death. In a country with frequent railway-related accidents, a complete autopsy is vital to determine the cause and mechanism of death, reconstruct the events before death, and identify the victim. It is also essential to determine whether the deceased died by suicide or homicide. This article reports an autopsy of a non-identified victim from a train crash with two fatal injuries. In addition, we reported the challenges in establishing the cause and manner of death. Case p resentation: A man was hit by a Pertamina train on Tuesday, 19 July 2022, at 00:24 West Indonesian Time (UTC+07:00), and this was reported to the police for investigation. The body was then examined at Dr. Soetomo General Academic Hospital by a forensic expert. The external examination suggested the presence of abrasions on the face, waist, and all four limbs, lacerations on the face and right earlobe, and open head fractures. In an internal examination, skull-base fractures, fourth and sixth right rib fractures, bleeding in the chest cavity, shrinking lungs, lacerations to the liver and lower right and left lungs, and blood infiltration in the chest cavity wall muscles and scalp muscles were found. The pneumothorax test was positive on the left chest but negative for heart air embolism. Investigation of the base of the skull revealed the presence of fractures. Conclusions: Determining the cause of death in a patient with multiple injuries was challenging and required a thorough investigation. Pneumothorax and air embolism could be the primary cause of death and their presence had to be investigated. Fractures of the base of the skull were established as the cause of death. According to the investigations at the crime scene and the injury profile, suicide was concluded as the manner of death.