The mission statement of forensic medicine is recognized and valued for the important and useful contribution to the promotion and protection of the well being of individuals and society. Forensic medicine provides comprehensive services and innovative programs that relate to medicolegal death investigation [1] [2]. Pattern injury recognition, interpretation of injuries, documentation of testimonial and injuries, reporting requirements, and regulations are all vital components of forensic evaluation. Multidisciplinary integration of technologies has been improved in contemporary forensic medicine. Besides, the medicolegal autopsy and histology other techniques and methods, such as molecular-genetic examinations [3] [4], post-mortem CT and MRI imaging [2] [5], post-mortem angiography [6] or corrosive method have been introduced into forensic medical practice. One of the main purposes of forensic post-mortem investigation is to differentiate between natural and violence death cases, and to define the cause of death. Forensic pathologists provide valuable information about the manner of death after the autopsy has been performed.

Types of manner-of-death

• Natural death is a death that results from a natural disease process. Natural deaths are the cause of the majority of deaths that occur. The post-mortem investigation reveals certain aspects of the death, whether it occurred suddenly or unexpectedly, or if the person was critically ill and had not seen a medical treatment previously.
• Homicide, meaning the killing of a human, where the criminal's intention was to deliberately cause someone's death. Some common examples of murdering include shooting, stabbing, smothering, strangling, hitting with a blunt object and burning.
• Accidental deaths are common to investigate post- mortem in forensic practice. In case, there is a suspect that the accident was deliberate or could have been avoided, a criminal investigation will be conducted.
• Suicide, meaning intentionally taking one's own life. Suicide is neither accidental nor is it classified as death by misadventure simply because the individual has set about on a course of action that would end with their own inevitable death. This would occur by drug overdose, cutting of one's wrists to induce uncontrollable bleeding, or stepping out in front of a moving vehicle.

Besides the classical four manner of death categories, there are several factors influence fatal natural and violent death cases. Based on the climate change, reports have been published about the concomitant climatic-environmental factors meteorological disasters and environmental pollution, a reasonable number of studies [7] [8] [9] [10]. The phenomenon of environmental death has a significant importance in the forensic evaluation of cause of death and manner of death. Climatic factors have direct impacts on fatal outcomes such as in traumatic shock or blunt trauma [11], animal sting anaphylaxis [12] [13], allergic disease [14], hypothermia [15][16], drawning [17] [18] or lightning [19]. However, the short-term or long-term influence on cardiovascular and respiratory system [20] [21] represents an important challenge for forensic pathologists. Meteorological conditions may influence the traumatic injuries and deaths in motor vehicle accidents too [22].

Climate change is potentially the largest global threat to human health ever encountered. Climatic and seasonal triggering factors on human life have received an increasing public and social interest. Patterns of meteorological elements such as temperature and precipitation have been altered due to climate change. In last years physicians and meteorologists pay attention on the relationship between meteorological events and their effects on human health [17] [23]. If the climatic constraints are strong enough, people may adapt with different stress reactions. The adaptability is strongly depends on age, gender, and health status [24]. However, the very strong, extreme, or long-lasting meteorological conditions may result in a serious damage of human health.

All the meteorological parameters have complex biological effects on human bodies [25] [26][27]. The most important meteorological parameters are: air temperature, humidity, wind speed, radiation, atmospheric motions, weather fronts, the air quality and air pollution. Statistical methods are used in growing number of medical science research, because they are capable to explore the complex relationship of the different climatic effects and the human health. Climatic research makes clear that Earth's climate will change in response to the atmospheric greenhouse gas accumulation [23]. Meteorological factors are well-known effect human health status and the rate of fatal cases. Detection and attribution of health effects to climate changes have become a key research challenge [28]. Climatic and seasonal triggering factors have received an increasing attention among risk factors of sudden death [26].

Several studies have demonstrated that cardiovascular mortality has a seasonal distribution [29] [30] [31] [32] [33]. The relationship between cold weather and ischeamic heart disease mortality is well established [27]. The cold temperature may be an important factor in bringing on the onset of life-threatening cardiac events [26]. The relationship between increasing temperature and mortality has been reported since the early 20th century.

McMichael et al. [23] pointed out that publications estimating via modeling and extrapolation how climate change will affect population health in the future were not extensive. Health outcomes are sensitive to isolated extreme events as very cold temperature, rainfall, heat waves, air pollution and flood. Windstorm damage could been extremely severe, and it is evident that both the frequency and severity of windstorm disasters are increasing. The great windstorms that affected a number of regions in recent years have attracted a great deal of attention throughout the world. Extreme events such as precipitation extremes and severe storms cause hundreds of deaths and injuries annually, and injuries and death are the direct health impacts very often associated with natural disaster. McGeehin and Mirabelli [24] suggest that the relationship between human health and stressful weather is a complex medical, social and environmental issue. McMichael et al. [23] suggest that the adverse health effects will indicate priorities for planned adaptive strategies. Kovats et al. [28] expect that the detection and attribution of health effects to climate changes have become a key research challenge.

Regarding to the mortality trends have been detected in the last decades the cardiovascular diseases and traumatic injuries represent a significant public health interest. Based on the international mortality datasets the leading causes of death in the developed countries are in connection with cardiovascular diseases and accidents [3] [34]. Cardiovascular disease was responsible for approximately 30% of death worldwide. It was estimated that the cardiovascular diseases will double from the year 1990 to the year 2020 [35]. Sudden cardiac death describes the unexpected natural death from a cardiac cause within a short time period, generally in one hour from the onset of symptoms, in a person without any prior condition that would appear fatal.

The frequency, intensity, and duration of meteorological disasters have also increased since 1920s [36] . Climate disasters, along with extreme meteorological events, heat waves, infectious diseases, water- and food-borne illnesses and air pollution are important components of climate change that impact mortality. Factors associated with greater vulnerability were living in coastal provinces and older age [9]. General experience of great earthquakes and tsunami event that survivors will have acute injuries and infections, and will be in increased risk of chronic illness, such as cardiovascular disease or mental ill.

However, there are publications about the reverse health effects of natural disasters from the US [37], Western Europe [38] and Asia [39]; until recently in Central Europe the societies have not faced many mass fatalities caused by extreme meteorological events. One of the pronounced climate trends of the past two decades is that in moderate latitudes, e.g., in Central Europe, winters are likely to become considerably milder, which may increase the risks of North Atlantic storms to intrude deeper into Western and Central Europe [40]. Reflecting on the event, the storm and the scope of the fatal cases, injuries and material damage, a question was arising, whether the disaster was a coincidence of meteorological conditions and social event.

In recent years, there has been growing demand from policy makers in health administration for better understanding of the relationship between meteorological conditions and various adverse health effects and mortality, because the threat to human health is significant. Detection of health effects due to climate change is essential and needs further investigation. It is suggested that the adverse health effects will indicate priorities for planned adaptive strategies. Natural deaths and violent deaths may be influenced by different weather conditions.

The forensic medical investigation and the co-operation between the medical experts and the local authorities or the police are important to discover all the information for differentiation between suicidal, accidental and intentional cases. Data of scene investigation, family history, detailed forensic autopsy, results of laboratory tests, have role in the examination of fatal cases. Further investigation about the characteristics injuries may help the final determination of violent death causes, and more effort should be directed to the effective prevention strategy. Detection of exact cause of death by forensic pathologists has a prominent role in the differentiation between violence and natural death. Characterization of environmental risk factors is important to determine preventative strategies against the global environmental changes. We can conclude that greater attention needs to be placed on the social context of climate change impact, the vulnerability and adaptation.

Keywords: Forensic medicine, Manner of death, Meteorological conditions, Climate change, Environmental death

1. De Winne J. Preparing for major incidents. Forensic Sci Int 2006 May 15;159 Suppl 1:S9–11.   [CrossRef]   [Pubmed]    
2. Roberts IS, Benamore RE, Benbow EW, et al. Post-mortem imaging as an alternative to autopsy in the diagnosis of adult deaths: a validation study. Lancet 2012 Jan 14;379(9811):136–42.   [CrossRef]   [Pubmed]    
3. Larsen MK, Nissen PH, Berge KE, et al. Molecular autopsy in young sudden cardiac death victims with suspected cardiomyopathy. Forensic Sci Int 2012 Jun 10;219(1-3):33–8.   [CrossRef]   [Pubmed]    
4. Sato T, Nishio H, Suzuki K. Sudden death during exercise in a juvenile with arrhythmogenic right ventricular cardiomyopathy and desmoglein-2 gene substitution: a case report. Leg Med (Tokyo) 2011 Nov;13(6):298–300.   [CrossRef]   [Pubmed]    
5. Poulsen K, Simonsen J. Computed tomography as routine in connection with medico-legal autopsies. Forensic Sci Int 2007 Sep 13;171(2-3):190–7.   [CrossRef]   [Pubmed]    
6. Jackowski C, Schweitzer W, Thali M, et al. Virtopsy: postmortem imaging of the human heart in situ using MSCT and MRI. Forensic Sci Int 2005 Apr 20;149(1):11–23.   [CrossRef]   [Pubmed]    
7. Watts N, Adger WN, Agnolucci P, et al. Health and climate change: policy responses to protect public health. Lancet 2015 Jun 24. pii: S0140-6736(15)60854–6.   [CrossRef]   [Pubmed]    
8. Hawkes N. Steps to combat climate change would also improve human health, commission says. BMJ 2015 Jun 23;350:h3416.   [CrossRef]   [Pubmed]    
9. Myung HN, Jang JY. Causes of death and demographic characteristics of victims of meteorological disasters in Korea from 1990 to 2008. Environ Health 2011 Sep 27;10:82.   [CrossRef]   [Pubmed]    
10. Schaffer A, Muscatello D, Broome R, Corbett S, Smith W. Emergency department visits, ambulance calls, and mortality associated with an exceptional heat wave in Sydney, Australia, 2011: a time-series analysis. Environ Health 2012 Jan 24;11(1):3.   [CrossRef]   [Pubmed]    
11. Bartels SA, VanRooyen MJ. Medical complications associated with earthquakes. Lancet. 2012 Feb 25;379(9817):748–57.   [CrossRef]   [Pubmed]    
12. Brown SG, van Eeden P, Wiese MD, et al. Causes of ant sting anaphylaxis in Australia: the Australian Ant Venom Allergy Study. Med J Aust 2011 Jul 18;195(2):69–73.   [Pubmed]    
13. Ruëff F, Chatelain R, Przybilla B. Management of occupational Hymenoptera allergy. Curr Opin Allergy Clin Immunol 2011 Apr;11(2):69–74.   [CrossRef]   [Pubmed]    
14. Shea KM, Truckner RT, Weber RW, Peden DB. Climate change and allergic disease. J Allergy Clin Immunol 2008 Sep;122(3):443–53.   [CrossRef]   [Pubmed]    
15. Miyazato T, Ishikawa T, Michiue T, Maeda H. Molecular pathology of pulmonary surfactants and cytokines in drowning compared with other asphyxiation and fatal hypothermia. Int J Legal Med 2012 Jul;126(4):581–7.   [CrossRef]   [Pubmed]    
16. Doberentz E, Preuss-Wössner J, Kuchelmeister K, Madea B. Histological examination of the pituitary glands in cases of fatal hypothermia. Forensic Sci Int 2011 Apr 15;207(1-3):46–9.   [CrossRef]   [Pubmed]    
17. Davis RE, Knappenberger PC, Michaels PJ, Novicoff WM. Changing heat-related mortality in the United States. Environ Health Perspect 2003 Nov;111(14):1712–8.   [CrossRef]   [Pubmed]    
18. Kakizaki E, Kozawa S, Imamura N, et al. Detection of marine and freshwater bacterioplankton in immersed victims: Post-mortem bacterial invasion does not readily occur. Forensic Sci Int 2011 Sep 10;211(1-3):9–18.   [CrossRef]   [Pubmed]    
19. Murty OP, Kian CK, Ari Husin MH, et al. Fatal lightning strikes in Malaysia. Am J Forensic Med Pathol 2009 Sep;30(3):246–51.   [CrossRef]   [Pubmed]    
20. Barnett AG, de Looper M, Fraser JF. The seasonality in heart failure deaths and total cardiovascular deaths. Aust N Z J Public Health 2008 Oct;32(5):408–13.   [CrossRef]   [Pubmed]    
21. Nielsen J, Mazick A, Glismann S, Mølbak K. Excess mortality related to seasonal influenza and extreme temperatures in Denmark, 1994-2010. BMC Infect Dis 2011 Dec 16;11:350.   [CrossRef]   [Pubmed]    
22. Piercefield E, Wendling T, Archer P, Mallonee S. Winter storm-related injuries in Oklahoma, January 2007. J Safety Res 2011 Feb;42(1):27–32.   [CrossRef]   [Pubmed]    
23. McMichael AJ, Wilkinson P, Kovats RS, et al. International study of temperature, heat and urban mortality: the 'ISOTHURM' project. Int J Epidemiol 2008 Oct;37(5):1121–31.   [CrossRef]   [Pubmed]    
24. McGeehin MA, Mirabelli M. The potential impacts of climate variability and change on temperature-related morbidity and mortality in the United States. Environ Health Perspect 2001 May;109 Suppl 2:185–9.   [CrossRef]   [Pubmed]    
25. Braga AL, Zanobetti A, Schwartz J. The effect of weather on respiratory and cardiovascular deaths in 12 U.S. cities. Environ Health Perspect 2002 Sep;110(9):859–63.   [CrossRef]   [Pubmed]    
26. Cagle A, Hubbard R. Cold-related cardiac mortality in King County, Washington, USA 1980-2001. Ann Hum Biol 2005 Jul-Aug;32(4):525–37.   [CrossRef]   [Pubmed]    
27. Gyllerup S. Cold climate and coronary mortality in Sweden. Int J Circumpolar Health 2000 Oct;59(3-4):160–3.   [Pubmed]    
28. Kovats RS, Hajat S, Wilkinson P. Contrasting patterns of mortality and hospital admissions during hot weather and heat waves in Greater London, UK. Occup Environ Med 2004 Nov;61(11):893–8.   [CrossRef]   [Pubmed]    
29. Weerasinghe DP, MacIntyre CR, Rubin GL. Seasonality of coronary artery deaths in New South Wales, Australia. Heart 2002 Jul;88(1):30–4.   [CrossRef]   [Pubmed]    
30. Arntz HR, Willich SN, Schreiber C, Brüggemann T, Stern R, Schultheiss HP. Diurnal, weekly and seasonal variation of sudden death. Population-based analysis of 24,061 consecutive cases. Eur Heart J 2000 Feb;21(4):315–20.   [Pubmed]    
31. Donaldson GC, Tchernjavskii VE, Ermakov SP, Bucher K, Keatinge WR. Winter mortality and cold stress in Yekaterinburg, Russia: interview survey. BMJ 1998 Feb 14;316(7130):514–8.   [CrossRef]   [Pubmed]    
32. Nakaji S, Parodi S, Fontana V, et al. Seasonal changes in mortality rates from main causes of death in Japan (1970--1999). Eur J Epidemiol 2004;19(10):905–13.   [Pubmed]    
33. Kloner RA. Natural and unnatural triggers of myocardial infarction. Prog Cardiovasc Dis 2006 Jan-Feb;48(4):285–300.   [CrossRef]   [Pubmed]    
34. Leijdesdorff HA, Siegerink B, Sier CF, Reurings MC, Schipper IB. Injury pattern, injury severity, and mortality in 33,495 hospital-admitted victims of motorized two-wheeled vehicle crashes in The Netherlands. J Trauma Acute Care Surg 2012 May;72(5):1363–8.   [CrossRef]   [Pubmed]    
35. Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of cardiovascular diseases: Part II: variations in cardiovascular disease by specific ethnic groups and geographic regions and prevention strategies. Circulation 2001 Dec 4;104(23):2855–64.   [CrossRef]   [Pubmed]    
36. Goklany IM. Climate change is not the biggest global health threat. Lancet 2009 Sep 19;374(9694):973–4.   [CrossRef]   [Pubmed]    
37. Dominici F, Levy JI, Louis TA. Methodological challenges and contributions in disaster epidemiology. Epidemiol Rev 2005;27:9–12.   [CrossRef]   [Pubmed]    
38. Gerritsen H. What happened in 1953? The Big Flood in the Netherlands in retrospect. Philos Trans A Math Phys Eng Sci 2005 Jun 15;363(1831):1271–91.   [CrossRef]   [Pubmed]    
39. De Valck E. Major incident response: collecting ante-mortem data. Forensic Sci Int 2006 May 15;159 Suppl 1:S15–9.   [CrossRef]   [Pubmed]    
40. Berz G. Windstorm and storm surges in Europe: loss trends and possible counter-actions from the viewpoint of an international reinsurer. Philos Trans A Math Phys Eng Sci 2005 Jun 15;363(1831):1431–40.   [CrossRef]   [Pubmed]