During the 19-year period (2001–2019), 344 autopsies of children and adolescents were performed at the Institute of Forensic Medicine in Milan. This represents 2% of all autopsies in the same period (more than 15.000). On average, only 18.10 ± 6.1 autopsies were performed in minors per year between 2001 and 2019. The highest number of cases was observed in 2004 (32 cases) and the lowest in 2019 (6 cases). Thus, there was a general downward trend of 80% approximately from 2004 to 2019. Overall, the autopsied minor population was composed of 235 males (68.3%) and 109 females (31.7%), for a male-to-female ratio of 2:1. In all years, the number of male juveniles autopsied was higher than the number of female juveniles, with the exception of only two years (2018 and 2019) in which the two sexes were equal (Fig. 1).

Number of minors autopsied at the Institute of Forensic Medicine in Milan from 2001 to 2019, with the breakdown into males and females for each year

Of these autopsies, 325 (94.5%) were ordered by the judicial authority, while the remaining 19 cases (5.5%) were clinical autopsies. Of the total number of minors, 267 (77.6%) were of Italian nationality, 22 (6.4%) were from Europe, 16 were from Africa (4.6%), and 8 were from Asia or South America (2.3% each); in the remaining cases, this information was not available.

The average age of the autopsied minors was 8.9 ± 5.7 years for males and 7.3 ± 6.4 years for females. Considering the number of autopsies performed according to the age of the underage deceased, it was observed that most cases occurred between the ages of zero and 1 year (88 cases, 25.6%), both in males (63 cases, 71.6%) and females (25 cases, 28.4%). Between the ages of 1 and 4 years, 55 cases (16%) occurred, with a slightly higher proportion in females than in males (26, 47%; females, 29, 53%). Between the ages of 5 and 9 years, 31 cases (9%) occurred, with almost equal proportions of male (16 cases, 51.5%) and female (15 cases, 48.5%) victims. Between the ages of 10 and 14, 51 cases (14.8%) were recorded, with most victims being male (36 cases, 70.5%). Between the ages of 15 and 17, the gap widened considerably, with 119 cases (34.6%) registered, of which 94 were males (79%) and 25 were females (21%). Further details are shown in Fig. 2.

Number of autopsies for each age of deceased minors

The place of death was the home in most cases (123 cases, 35.7%), followed by the street (101 cases, 29.3%) and the hospital (68 cases, 19.7%). In the remaining cases, deaths occurred in public places (22 cases, 6.4%), hotels (10 cases, 3%), bodies of water (8 cases, 2.3%), and the workplace (5 cases, 1.4%); in the remaining cases, this information was not available.

Regarding the manner of death, accident was the most common (155 cases- 45.1%, 100 males and 55 females), followed by natural death (129- 37.5%, 94 males and 35 females), suicide (37- 10.7%, 31 males and 6 females), and finally homicide (23 cases- 6.7%, 10 males and 13 females). In all manners of death, with the exception of homicide, the male sex was numerically more represented.

In terms of age, the number of deaths from natural causes decreased from 68 in babies until 1 year (52.7%) to 27 between 1 and 4 years (21%) and 7 between 5 and 9 years (5.4%), and then increased slightly to 11 between 10 and 14 years (8.5%) and 16 between 15 and 17 years (12.4%). An opposite trend was observed for suicides and accidents. Suicides occurred in the age group between 5 and 9 years with only 1 case (2.7%) and then increased to 11 cases between 10 and 14 years (29.8%) and 25 cases between 15 and 17 years (67.5%). Accidental deaths, on the other hand, were documented in babies until 1 year with 13 cases (8.5%) and then increased with age: 21 cases between 1 and 4 years (13.5%), 19 cases between 5 and 9 years (12.3%), 28 cases between 10 and 14 years (18%), and 74 cases between 15 and 17 years (47.7%). Homicides were represented in all age groups, with 7 cases in babies until 1 year and between 1 and 4 years (30.4% each), 4 cases between 5 and 9 years (17.4%), 1 case between 10 and 14 years (4.4%), and 4 cases between 15 and 17 years (17.4%).

As for non-natural causes of death, the breakdown of victims by sex showed that suicide was a phenomenon that affected the male sex much more frequently than the female one and the first case was observed as early as age 9. In homicides, both sexes were affected, although females were generally more frequently involved, especially up to the age of 4 years and between 15 and 17 years; overall, most homicides were committed between the ages of 0 and 9 years. Finally, deaths from accidents affected all age groups, with the difference between males and females increasing with age (the only exception was the 5–9 age group). Further details are shown in Table 1.

A detailed examination of all non-natural causes of death (215 cases in total, 141 males and 74 females) revealed that blunt force trauma was by far the most common method of injury (144 cases, 67.0%), followed by asphyxia in 36 cases (16.7%), acute intoxication in 11 cases (5.1%), sharp force trauma in 10 cases (4.6%), firearm in 6 cases (2.8%), electric injury and neglect in 3 cases each (1.4% each), and thermal injury in 2 cases (1%). Breaking down methods of injury by manners of death, it was observed that accidental deaths were most frequently caused by blunt force trauma (traffic accidents – 84 cases, and falls – 37 cases), followed by asphyxia (drowning – 11 cases, and food inhalation – 8 cases), acute intoxication (overdose of illicit drugs – 8 cases), electrical injuries – 3 cases, thermal injuries – 2 cases, and sharp force trauma – 2 cases. Similarly, among suicides, the most common method of injury was blunt force trauma (fall from height – 19 cases), followed by asphyxia (hanging – 7 cases, plastic bag suffocation – 5 cases); other methods consisted of gunshot wounds – 3 cases, and acute intoxication (CO poisoning – 3 cases). In contrast, most homicides were due to sharp force trauma – 8 cases, and asphyxia (choking – 1 case, strangulation – 2 cases, and suffocation – 2 cases), followed by blunt force trauma – 4 cases, gunshot wounds – 3 cases, and neglect – 3 cases (Fig. 3).

Total methods of injury for suicide, homicide and accidental event, broken down by gender of victims, with details of raw number and percentage value (%) of the total in each category

Relating the various methods of injury to the age of the victims, it was observed that blunt force trauma always took the first place in every age range. This was particularly striking in victims younger than 4 years and in victims 14 years or older. Asphyxia was the second most common finding across all age groups, affecting both children and adolescents. Acute substance intoxication was recorded in the range of 10 to 17 years; sharp force trauma, electrocution, and thermal injuries predominated between 15 and 17 years. All cases of neglect involved newborns or infants. When the methods of injury were considered by both victims’ age and manner of death, it was apparent that blunt force trauma predominated among accidental deaths in all age groups, followed almost without exception by death due to asphyxia. Ages 1 to 4 years also recorded the first case of accidental electrocution, while ages 10 to 14 years recorded accidental deaths from sharp force trauma and acute intoxication. These injury patterns continued from 15 to 17 years of age, with accidental thermal injuries also occurring. The first case of suicide was a 9-year-old child who died by asphyxia (hanging); between 10 and 14 years, the number of suicide cases increased to 11, all of them carried out through blunt force trauma and asphyxia exclusively. Between the ages of 15 and 17 years (25 cases), a more differentiated framework emerged: in addition to blunt force trauma (which was predominant), suicidal deaths by asphyxia, sharp force trauma and gunshot wounds were also recorded. Among homicides, blunt force trauma, asphyxia, and gunshot wounds were fairly evenly distributed across all age groups, with sharp force trauma slightly predominating. Neglect also occurred in newborns and infants, while firearm use was seen between ages 1 and 4 and between ages 15 and 17 (Table 2). Focusing on blunt force trauma only, which is by far the most significant in terms of numbers, it was observed that most fatal accidents up to the age of 14 were due to traffic accidents involving minors, mainly as victims of hit-and-run accidents or as passengers in cars. After age 15, car accidents continued to predominate, but there was also an increase in the number of motorcycle accidents involving minors, primarily as drivers. Fatal fall accidents were recorded mainly among 5- to 14-year-olds at play (falls from rides, trees, and less frequently from balconies). Blunt injuries in suicides were exclusively from falls from great heights. Among homicides, there were two cases of shaken baby syndrome in children under 4 years of age; the other cases were blunt injuries from blows with the bare hands combined with blunt tools.

From the ISTAT (National Institute of Statistics) survey it was observed that about 2000 minors (0–17 years) died in Milan (surroundings included) between 2001 and 2019. This number included deaths due to both natural and non-natural causes. The data of the two extreme years were assessed: in 2001, 88 minors died and 22 (25%) were autopsied; in 2019, 71 died and only 6 (8%) were autopsied. Therefore, a decrease of about 70% was recorded.

An in-depth look at deaths due to non-natural causes alone in minors between 2015 and 2019 in the Milan region revealed 86 deaths. A comparison with data from the Institute of Forensic Medicine showed that of these victims, only 33 underwent a forensic autopsy. It followed that the remaining 53 cases (about 61%), although they died of non-natural causes, were not examined by a forensic pathologist. Details on these cases was taken from ISTAT forms, as reported by the physicians who filled them in. In some cases, the information was missing. Specifically, the cases involved 35 children aged 0 to 9 years (66%) and 18 aged 10 to 17 years (34%). Overall, 25 cases (47%) were fatal accidents, 17 cases (32%) were suicides, and 11 cases (21%) had no information. Finally, blunt force trauma was reported in 31 cases (59%), asphyxia in 14 cases (26%), thermal injury in 2 cases (4%), and no information was available in the remaining 6 cases (11%).