Journal of Forensic and Legal Medicine 61 (2019) 17–21

Contents lists available at ScienceDirect

Journal of Forensic and Legal Medicine

journal homepage: www.elsevier.com/locate/yjflm

Research Paper

A study of fatal falls from height T

a b,∗ c
Abdurrahim Türkoğlu , Kerem Sehlikoğlu , Mehmet Tokdemir
a
Forensic Medicine, Medical Faculty, Firat University, Elazig, Turkey
b
Forensic Medicine, Medical Faculty, Adiyaman University, Adiyaman, Turkey
c
Forensic Medicine, Medical Faculty, Katip Celebi University, Izmir, Turkey

ARTICLE INFO ABSTRACT

Keywords: Introduction: and Objective: Falling from a height is one of the main causes of blunt force trauma. Frequently
Falls seen in accidents or for the purpose of suicide, it can result in disability or death. The aim of this study is to
Accidents investigate the characteristics of fatalities due to falling from a height.
Autopsy Materials and methods: This study retrospectively examines 213 cases of fatal falls from a height that had oc-
Injuries
curred in and around Elazığ province between January 2005 and December 2016. All the victims’ autopsies were
Height
performed. The cases were reviewed in terms of such variables as gender, age, the month and season in which
the incident took place, the cause of the fall, the location of the fall, the height of the fall, the injury site and the
cause of death.
Results: It was determined that the falls were caused by: Accident in 171 (80.3%) cases, suicide in 41 (19.2%)
cases and homicide in 1 (0.5%) case. Of these cases, 144 (67.6%) were men and 69 (32.4%) were women. In our
study, the youngest case was aged 9 months while the eldest was 91 years, the average age being 43.6 ± 27.4
years. It was determined that 60.6% of the cases had fallen in their homes.
Conclusion: In conclusion, it was observed that fatalities from height are mainly the result of an accident and
thus preventable. Since fatalities were more common in the aged and in children, it was thought that protective
measures should be implemented specifically for these groups such as appropriate planning and family educa-
tion.

1. Introduction fatal falls from a height that had undergone autopsy at the Firat
University Hospital which had occurred in and around Elazığ Province
Falling from a height is one of the main causes of blunt force in the east of Turkey between January 2005 and December 2016. The
trauma.1 These falls are frequently seen in accidents or for the purpose cases were reviewed in terms of the following variables: gender, age,
of suicide. The victims can be killed or left with permanent injuries.1,2 age group, the month the incident took place, the location of the in-
The age of the victim, the height of the fall, the speed of the fall, the cident (rural - urban), the cause of the fall (accident, suicide, homicide),
nature of the impact surface, the part of the body that hit the ground the height of the fall, the place of the fall, the site of the fall, the interval
first, the duration of the mechanical effect and how the body reacts to between the incident and death, the place where death occurred, the
this effect are all prognostic factors used to predict the severity of the region of injury, the cause of death, the presence of fractures in the
injury and the chances of survival.1–3 extremities/ribs, any history of psychiatric or organic illness and, if any,
The aim of this study was to examine fatal falls from height in terms the use of toxic substances. This study is based on the data provided by
of such variables as gender, age, the cause of the fall, the location of the crime scene reports and images that had been made available as well as
fall, the height of the fall, the injury site and the cause of death, to eyewitness testimonies, medical histories/records, and autopsy reports.
determine whether any relationship existed, and to compare the ob- Histories provided by the victims' relatives were also taken into con-
tained results with similar studies. sideration. The ages of the cases were grouped by decade. Settlements
with a population of less than 20,000 were classified as rural areas
2. Materials and methods while those with a population exceeding this were classified as urban.
As a result of our examination and review of the available information
In this study, we retrospectively examined a total of 213 cases of and findings, this study includes cases where the causes of the fall had

∗
Corresponding author. Siteler Quarter, Atatürk Boulevard, No: 411, Adiyaman University, Deanery of the Faculty of Medicine, Adiyaman, Turkey.
E-mail addresses: [email protected], [email protected] (K. Sehlikoğlu).

https://doi.org/10.1016/j.jflm.2018.10.008
Received 15 April 2018; Received in revised form 8 September 2018; Accepted 24 October 2018
Available online 26 October 2018
1752-928X/ © 2018 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
A. Türkoğlu et al. Journal of Forensic and Legal Medicine 61 (2019) 17–21

been identified. Fall height was categorized into two groups: high Table 2
(> 5 m) and low (< 5). For falls from buildings, the average height of Place of fall.
each storey was calculated as 3 m. Cases, where the height of the fall Location n %
had not been fully determined, were not included in the study. The
cases were examined by injury region: head/neck, thorax, abdomen/ Home/Residential building 129 60.6
Construction Site 23 10.8
pelvis or extremities. In terms of the causes of death, the cases were
Garden 16 7.5
reviewed in three main groups depending on the region of the injury: Working Place 15 7.0
head/neck injuries, thoracic/abdominal injuries and fatal injuries to Hospital 13 6.1
multiple areas. In all cases, the cause of death was determined based on Road 10 4.7
macroscopic findings. Toxicology screens looking for ethyl alcohol in Mountain/Cliff 7 3.3
Total 213 100.0
the blood and cannabis, heroin, cocaine, methadone, benzodiazepine
and amphetamines in the urine were examined.
The categorical variables in the study were given as frequency and significant rate than men and that men fell by accident more frequently
percentage while the descriptive statistics and continuous variables than women did (χ2: 6.101, SD: 1, p = 0.014). With the average age of
were given as mean ± standard deviation. The categorical variables accidental fatalities being 43.0 and the average age of suicides being
were grouped, the percentages calculated and then either Pearson's Chi- 46.0 no significant difference was found between both groups' average
Square Test or Fisher's Test as appropriate was used to compare fre- ages (p = 0.44). However, it was determined that the average age of
quencies. The Kolmogorov Smirnov test was used for normality in suicides among men was significantly higher (p = 0.02). The rate of
continuous variables (p > 0.05). The t-test was used for the in- accidental deaths among the extreme age groups (61 + and 0–10 years)
dependent samples when evaluating the average differences between was found to be 56.7% while suicides were most frequently seen in the
the two groups. All statistical analyses, tables, and charts were made 21–30 age group (n = 14) followed by the 61 + age group (n = 13)
using the SPSS 22 (IBM Corp., Armonk, NY) program. Cases with a P (Table 1). One case was treated as murder after it was determined that
value of < 0.05 were considered significant. A relationship between the the body had been dragged to a nearby riverbank after being thrown
variables was statistically proven to exist. from a height.
In terms of the height of the fall, it was determined that 120 cases
3. Results (56.3%) had fallen from high heights and 93 cases (43.7%) from low
heights. The fall height was found to be significantly higher in suicide
Of the 2591 cases that had been given a post-mortem examination cases than in accidental falls (χ2: 27.578, SD:1, p < 0.001). In both
and/or autopsy between January 2005 and December 2016, the study genders, suicides were observed to have jumped from higher height
investigated the 213 (7.2%) fatalities caused by falling from a height. (Table 1).
All the cases of the study has been undergone autopsy. It was determined that 60.6% of the cases had fallen at home fol-
Of these cases 144 (67.6%) were men and 69 (32.4%) women. The lowed by 10.8% at construction sites (Table 2). It was determined that
youngest case in our study was aged 9 months while the eldest was 91 the most common site for falls was the balcony (27.7%) followed by
years, the average age being 43.6 ± 27.4 years. The average age for windows (20.2%) then roofs (14.1%) (Table 3). Of the 41 suicide cases,
male cases was 46.7 ± 26.0 and 37.1 ± 29.2 for female cases. 39 (95.1%) were noted to have jumped from a balcony or a window.
When the fatalities were evaluated by age group, they were found to It was determined that 39.4% of the cases died at the scene or en
occur most frequently in the group 61 years and older with 69 cases route to the hospital while 60.6% died while being treated in hospital. It
(32.4%) while the second most frequent occurrence was observed in the was understood that 60.1% died within the first 24 h, 21.6% within two
0–10 age group with 41 cases (19.2%) (Table 1). to seven days and that 18.3% died later than seven days after the in-
It was also seen that the cases were more frequent (56.4%) in the cident (Fig. 1).
period May to September, that time of the year when the average The most common injury site in the cases was found to be the head/
temperatures are high. It was determined that 65.3% of the incidents neck (84.5%) followed by the thorax (62.4%), the abdomen/pelvis
happened in urban areas. (42.7%) and the extremities (34.7%) (Table 4). When the causes of
Of the cases, 171 (80.3%) were found to have fallen by accident, 41 death of the cases were examined, the most common injuries observed
(19.2%) were suicides with 1 (0.5%) homicide. Among the accidental were in multiple areas (49.3%), followed by solely head/neck injury
deaths, 122 were men, and 49 were women while 21 of the suicide (37.1%) and internal organ injury and/or internal bleeding (only single
jumpers were men and 20 were women (Table 1). It was found that region) (8.9%). Additionally, it was determined that eight cases died of
women preferred to jump to their deaths at a statistically more sepsis and two from spinal shock (Table 5). It was also seen that 74.6%
(n = 159) suffered fatal head/neck injuries. While it was determined
Table 1
that 112 cases had skull fractures, it was understood that 71 of them
Distribution of accident and suicide-related falls by age group and fall height.
Accident Suicide Table 3
Site of fall.
Male Female Total Male Female Total
Location n %
Age Group
0-10 21 20 41 (24.0%) – – – Balcony 59 27.7
11-20 6 3 9 (5.3%) – 2 2 (4.9%) Window 43 20.2
21-30 9 – 9 (5.3%) 3 11 14 (34.1%) Rooftop 30 14.1
31-40 15 – 15 (8.8%) – 2 2 (4.9%) Scaffolding 16 7.5
41-50 16 4 20 (11.7%) 4 – 4 (9.8%) Stairs 15 7.0
51-60 17 4 21 (12.3%) 5 1 6 (14.6%) Tree 15 7.0
≥61 38 18 56 (32.7%) 9 4 13 (31.7%) Bed/Household Furniture/Table/Chair 10 4.7
Height Motor Vehicle 9 4.2
<5m 64 26 90 (52.6%) 2 1 3 (7.3%) Mountain/Cliff 7 3.3
>5m 58 23 81 (47.4%) 19 19 38 (92.7%) Others 9 4.2
Total 122 49 171 (100.0%) 21 20 41 (100.0%) Total 213 100.0

18
A. Türkoğlu et al. Journal of Forensic and Legal Medicine 61 (2019) 17–21

Fig. 1. Interval between incident and death.

Table 4 and suicide-related cases (n = 202), it was determined that instances of

Anatomical regions of injuries. fatal injuries to multiple areas were significantly higher in suicide cases
Injury Regions n %
(χ2: 12.753, SD:2, p = 0.002) (Table 7). This study also revealed that
cases with solely head/neck injuries occurred more frequently in falls
Head & Neck 180 84.5 from low heights, and cases with fatal injuries to multiple areas oc-
Thorax 133 62.4 curred more frequently in falls from high heights (χ2: 37.270, SD: 2,
Abdomen & Pelvis 91 42.7
Limbs 74 34.7
p < 0.001) (Table 7).
42.3% of the cases had fractures of the ribs, and 34.7% had ex-
tremity fractures. It was understood that the greater the height of the
Table 5 fall, the more frequent occurrences of broken ribs (χ2: 9.981, SD:1,
Causes of death in falls from height. p = 0.002) and broken extremities (χ2: 22.394, SD:1, p < 0.001).
Injuries to the major arteries were seen in 27 cases. Of these injuries,
Causes of Death n %
11 were to the descending aorta, 6 to the other major arteries (renal,
Polytrauma 105 49.3 femoral, left iliac artery), 4 to the aortic arch, 4 to the ascending aorta
Solely Head/Neck Injury 79 37.1 and 2 to both the ascending aorta and aortic arch.
Internal Organ Injury and/or Internal Bleeding (only single region) 19 8.9 It was noted that in 15% of the cases (n = 32) there was a history of
Sepsis 8 3.8
Spinal Shock 2 0.9
psychiatric or organic illness: 13 cases of depression, 8 cases of
Alzheimer's, 7 cases of cerebrovascular disease and 4 cases with other
illnesses (schizophrenia, loss of sight etc).
Table 6 Toxicological analysis of blood and urine samples taken from the
Distribution of fatal head injuries. cases detected ethyl alcohol in the blood in 2 cases and heroin in the
urine in just 1 case. No toxic substances were detected in the samples
Injury Locations n %
taken from the other cases.
Skull Base + Cranial Vault Fracture 71 33.3
Cranial Vault Fracture 24 11.3 4. Discussion
Skull Base Fracture 17 8.0
Subarachnoid Hemorrhage 54 25.4
Subdural + Subarachnoid Hemorrhage 38 17.8 Injuries and fatalities caused by falling from a height are a world-
Cerebral Laceration and/or Loss 15 7.0 wide health problem requiring care and attention.4 It is one of the
Epidural + Subdural + Subarachnoid Hemorrhage 10 4.7 common causes of traumatic death, especially in developed countries.5
Others 25 11.7 With the increase in urbanization, tall buildings have been or are being
made in confined living areas. Therefore, falls from height are com-
monly seen occurrences among people living in these buildings or
Table 7
working on their construction.6
Causes of Death in Accident and Suicide-Related Cases based on the Height of
the Fall.
The fact that 67.6% of the cases in this study were male was found
in line with Gören1 's (61.2%) and Thierauf7 's (74.9%) studies. In their
Causes of Death Accident Suicide study Peng et al.5 showed that the rate for men was lower (53.7%)
<5m >5m Total <5m >5m Total
while Behera6 showed it to be higher (79.3%). The high rate for men
has been ascribed to men taking more risks than women and working in
Solely Head/Neck Injury 48 23 71 2 6 8 dangerous employment sectors like construction more than women do.
Internal Organ Injury & 14 4 18 – 1 1 It was also thought that gender rates were affected by the socio-cultural
Internal Bleeding (only
single region)
and economic differences between societies.
Polytrauma 23 51 74 1 29 30 When the cases were evaluated by age group it was seen that they
Total 85 78 163 3 36 39 occurred most often in the 61 + years age group with 69 instances
(32.4%) followed by the 0–10 years age group with 41 instances
(19.2%). Similarly, in the study by Goren et al. (55.0%) the instances
had both skull base and cranial vault fractures, 24 had only cranial were found to occur at a greater rate (n = 51.6%) in the extreme age
vault and 17 had only skull base fractures. Intracranial hemorrhage was groups.1 Among senior citizens there is still a high risk of mortality even
seen in 66.7% of the cases (n = 142) while subarachnoid hemorrhage in low energy falls due to preexisting illnesses and physical frailties.1,8
was seen in 25.4%, subarachnoid hemorrhage + subdural hemorrhage Furthermore, these individuals have longer stays in hospital and higher
in 17.8% and brain laceration and/or loss in 7.0% (Table 6). When it follow-up rates than young people, and this is not unexpected.9 In their
was compared causes of death (excluding the deaths by sepsis and study S. Kafadar and H. Kafadar reported incidents of children falling
spinal shock due to the cases being limited in number) with accident when playing in dangerous places without parental supervision and

19
A. Türkoğlu et al. Journal of Forensic and Legal Medicine 61 (2019) 17–21

that in order to decrease the number of such incidents parents needed to been detected because some individuals in the region do not consider
warn their children about playing in dangerous places and take ne- psychiatric illnesses to be serious enough illnesses. It could also be that
cessary precautions in risky areas such as windows, balconies, and they do not administer the necessary precautions or because the sam-
stairs.2 Head injuries are more frequent in children because their cen- ples taken from the victims for toxicology screening were not screened
ters of gravity are higher up due to the disproportionately large size of for psychological or neurological medicines apart from benzodiazepine.
their heads compared to their bodies.2,3 Behera6 stated in his study that The fact that toxic substances were seen in just three cases when
accidental falls in children and senior citizens were preventable. screened for the use of toxic substances was attributed to the fact that
It was also seen that the instances occurred more frequently (56.4%) most of the incidents were accidents and that the cases were mainly in
in the period May to September, the time of the year when average the extreme age groups. Furthermore, this study considered that due to
temperatures are high, and it was understood that this was in line with religious beliefs and traditions alcohol and drug use is very low, par-
similar studies made in eastern Turkey.1,2 Since the rate of accidental ticularly in rural areas.
falls during this period was seen to be 58.5% it was thought that they
were the result of more windows and balconies being used for cooling 4.1. Limitations
purposes as the temperatures rise.
The fact that 60.6% of the instances were falls from houses is in line Our study on fatal falls from height was limited in several respects.
with the study by Behera et al.6 (68.9%). It was observed that 63.4% of The first could be that the reasons for falling could not be clearly dif-
suicides were jumps from heights at home and 26.8% from heights ferentiated in our study. Eyewitness accounts, security camera footage,
while in hospital. Risk factors for suicide among senior citizens include the existence of a suicide note and whether or not the victim had a
retirement, losing a loved one, loneliness, disability and accompanying previously known illness are mostly helpful in determining the reasons
chronic illnesses.10 The fact that 59.6% of accidental incidents occurred for falling. It is harder to determine the cause of death in incidents
at home is in line with the study by Peng et al.5 (57.1%). In our study where such conditions are missing. In order to reduce the margin of
the most common cases were falls from balconies (27.7%) whereas in error that could result from this all the information and findings per-
the studies by Behera et al.6 and Goren et al.1 the most common cases taining to the cases were examined in detail. Secondly, it was not
were falls from roofs. It was concluded that balconies were used more known what type of surface the victim struck or which part of the
often in daily life but the roofs were kept closed due to climate con- victim's body hit the ground first, and these are important factors af-
ditions or they were not preferable because of the sloping land in the fecting mortality.
area where our study was done.
It was found that 80.3% of the cases were accidental, 19.2% were 5. Conclusion
suicides, and 0.5% was the result of homicide. It was determined that
the rate of accident-related falls was in line with the studies by Goren In conclusion, it was observed that fatalities from height are mainly
et al.1 (89.0%) and Murthy11 (88.5%), lower than Behera6 (97.7%) and the result of an accident and thus preventable. Since fatalities were
higher than Li and Smialek12 (51.8%) and Peng et al.5(43.8%). The more common in the aged and in children, it was thought that pro-
different rates of instances seen in similar studies on this topic were tective measures should be implemented specifically for these groups
mainly attributed to the practicality of the measures taken by societies such as appropriate planning and family education.
to counter falls from height.
This study demonstrated that the average age of accidental fatalities Note
was lower than suicide cases, and this was mostly male victims.
Inversely, The study by Peng et al. showed the average age of suicides This article has been presented as a poster presentation at the 14th
was lower than accidental fatalities and that this was mostly female Forensic Science Congress between May 11–14, 2017. The authors de-
cases. It was thought that the methods chosen to commit suicide differ clare no conflict of interest. No financial support was received while the
among societies. Furthermore, the fact that women choose to jump as a work was being organized.
means of suicide at a significantly more meaningful rate than men while
men are seen to fall by accident more frequently than women is in line Acknowledgement
with similar studies.1,5
When reviewing fall heights, it was understood that in their study The authors present our thanks to Ayşe Vlok, for her assistance in
Goren and Wang split this into two groups: high (> 5 m) and low proofreading and improving our article, and Dr. Şeyma Sehlikoğlu, who
(< 5 m).1,13 The fall height for the cases was similarly divided in our has contributed in the writing of the our article.
study. The fact that fall height for the suicide group was higher than of
accidents was found to be in line with similar studies.14,15 References
The most common anatomical region of injury in the cases was
found to be the head/neck (84.5%) followed by the thorax, the ab- 1. Goren S, Subasi M, Týrasci Y, Gurkan F. Fatal falls from heights in and around
domen, and the extremities. This was seen to match the study by Goren Diyarbakir, Turkey. Forensic Sci Int. 2003;137(1):37–40.
2. Kafadar S, Kafadar H. The medico-legal evaluation of injuries from falls in pediatric
et al.1 Death due to head/neck injury was observed in the vast majority age groups. Journal of Forensic and Legal Medicine. 2015;31:52–55.
of the cases (74.6%), and this was found to be in line with previous 3. Lapostolle F, Gere C, Borron SW, et al. Prognostic factors in victims of falls from
studies.6,16 Instances of fatal injuries to multiple sites in falls from high height. Crit Care Med. 2005;33(6):1239–1242.
4. Landy DC, Mintzer MJ, Dearwater SR, Graygo JA, Schulman CI. Fatal falls in an
heights were seen frequently, which is also in line with the study by ethnically Diverse urban community: the link between Demographic factors and the
Goren et al.1 Since broken ribs and extremities were seen more fre- circumstances surrounding fatal falls. South Med J. 2012;105:405–410.
quently as fall height increased it was thought that there was a direct 5. Peng TA, Lee CC, Lin JCC, Shun CT, Shaw KP, Weng TI. Fatal falls from height in
taiwan. J Forensic Sci. 2014;59(4):978–982.
proportion between fall height and trauma intensity. Other studies have
6. Behera C, Janani S, Murty OP. Fatal fall from heıght in south Delhi (1996-2005): a
also shown an increase in the rates of death and serious injury as the fall retrospectıve study. Journal of Forensic Medicine and Toxicology. 2014;31(2):23–26.
height increases.3,6,11,17 The fact that 60.1% of the cases in this study 7. Thierauf A, Preuß J, Lignitz E, Madea B. Retrospective analysis of fatal falls. Forensic
Sci Int. 2010;198(1):92–96.
died within the first day indicates the traumatic severity of falling from
8. Gelbard R, Inaba K, Okoye OT, et al. Falls in the elderly: a modern look at an old
heights. problem. Am J Surg. 2014;208(2):249–253.
What stood out in our study was that only 15.0% of the cases had ̇
9. Kennedy RL, Grant PT, Blackwell D. Low-impact falls: Demands on a system of
histories of psychiatric or neurological illness. This situation was con- trauma management, prediction of outcome and influence of comorbidities. Journal
of Trauma and Acute Care Surgery. 2001;51(4):717–724.
sidered to be the result of illnesses that the cases might well have not

20
A. Türkoğlu et al. Journal of Forensic and Legal Medicine 61 (2019) 17–21

10. Juurlink DN, Herrmann N, Szalai JP, Kopp A, Redelmeier DA. Medical illness and the 14. Turk EE, Tsokos M. Pathologic features of fatal falls from height. Am J Forensic Med
risk of suicide in the elderly. Arch Intern Med. 2004;164(11):1179–1184. Pathol. 2004;25(3):194–199.
11. Murthy CV, Harish S, Chandra YG. The study of pattern of injuries in fatal cases of 15. Gill JR. Fatal descent from height in New York city. J Forensic Sci.
fall from height. Al Ameen J Med Sci. 2012;5(1):45–52. 2001;46(5):1132–1137.
12. Li L, Smialek JE. The investigation of fatal falls and jumps from heights in Maryland 16. Kohli A, Banerjee KK. Pattern of injuries in fatal falls from buildings. Med Sci Law.
(1987-1992). Am J Forensic Med Pathol. 1994;15(4):295–299. 2006;46(4):335–341.
13. Wang MY, Kim KA, Griffith PM, et al. Injuries from falls in the pediatric population: 17. Dickinson A, Roberts M, Kumar A, Weaver A, Lockey DJ. Falls from height: injury
an analysis of 729 cases. J Pediatr Surg. 2001;36(10):1528–1534. and mortality. J Roy Army Med Corps. 2012;158(2):123–127.

21