Toxicological insights into sharp force-related homicides: A retrospective study at Tygerberg mortuary, Cape Town,...

Sharp-force fatalities represent a major proportion of homicidal deaths in South Africa, yet the contribution of alcohol and drugs of misuse and abuse to these incidents remains poorly characterised. This retrospective, cross-sectional study reviewed 248 sharp-force fatalities admitted to a large urban forensic service in Cape Town during 2024. Demographic, injury, and toxicological data were extracted from forensic records, and post-mortem blood and urine specimens were analysed using validated headspace gas chromatography for alcohol and liquid chromatography-tandem mass spectrometry targeting 29 drugs. Blood alcohol was detected (>0.01 g/100 mL) in 66.1% of tested cases, while 140 cases (56.5%) were positive for at least one drug. The most frequently identified analytes were 11-nor-9-carboxy-tetrahydrocannabinol (29.0%), methaqualone (27.0%), and methamphetamine (25.8%). Polydrug use occurred in 57.6% of drug-positive cases, most commonly involving methaqualone and methamphetamine, demonstrating a recurrent stimulant-sedative co-use pattern. Of the 140 drug-positive cases, 72 (51.4%) had blood alcohol concentrations below 0.05 g/100 mL, including those with no detectable alcohol, indicating that alcohol was unlikely to have been a major contributing factor in many of these fatalities. These findings demonstrate that psychoactive substances are frequently detected in individuals who die from sharp-force injuries and suggest that intoxication, particularly involving multiple substances, may contribute to impaired judgment, aggression, or increased vulnerability to violence. The results underscore the importance of comprehensive post-mortem toxicological investigations and the integration of toxicological patterns into violence-prevention initiatives and public health strategies.