Trauma contributes significantly to mortality in childhood [8]. The aim of this study was to analyze injury patterns in relation to trauma mechanism and subsequent causes of death. Although mechanisms of injury vary between age groups, vehicle and fall-related injuries were most common mechanisms in all age groups. A suicidal motivation was identified in 17 out of 71 patients, and 40% of all fatalities between 14 and 18 years committed suicide. Most common cause of death in children up to the age of 13 was traumatic brain injury (59%) while adolescents died more often from polytrauma (55%). Overall, 75% died within 24 h of the event, which is in line to other studies reporting similar rates [9].

Various studies worldwide have shown that traffic accidents are the most common cause of trauma and the leading cause of death in children [3, 10,11,12]. In our study, 40% deaths were related to traffic accidents. Comparable to other studies, we observed lower percentages of traffic accidents in the lower age groups, however, percentages increased significantly in older patients [12]. Most fatal traffic accidents in 14–18 years old victims occurred as pedestrians and two-wheelers, which can be explained by the increasing participation in road traffic. The predominant victims in this age group were male. Age-dependent behavioral changes and an increasing willingness to take risks – especially in male children – may also contribute to the frequency of severe trauma in adolescents. Traumatic brain injury was the leading cause of death in fatal traffic accidents. Previous studies in adults revealed that pedestrians – followed by cyclists – are the most vulnerable group among traffic accident victims with the highest risk of traumatic brain injury [13, 14]. Children have several anatomical differences that may predispose them to injury such as a more vulnerable cranial vault due to thinner bones and a larger head-to-torso ratio [6]. Therefore, children might be at even greater risk of injury than adults who experience a comparable trauma. In the present study, 5 patients died due to accidents with two-wheels. Cycling does not require mandatory helmet use in Germany, which may contribute to an increased risk of head injury after fall. However, strategic measures such as infrastructural improvements in roads, speed limits or autonomous braking systems may certainly also have great influence on children’s’ safety in traffic.

As already reported in previous studies, falls from height > 3 m account for an important proportion of pediatric trauma and childhood mortality [3, 4]. In the presented study, falls from height > 3 m were the most common cause of trauma in children aged 0–6 years. Regarding our data, 22 (31%) patients died from falls from height > 3 m due to unintended accidents, suicides and third-party violence. Height and speed of the fall determine the severity of the injury, however, due to numerous determinants, correlations between height and corresponding injury pattern remain challenging [15]. In our study, drop height was only categorized in “ground level fall” and “fall from height > 3 m”. Nevertheless, the comparison of injury pattern in deceased patients with fatal traffic accidents and falls from height > 3 m revealed major differences.

The injury pattern in falls from height > 3 m revealed severe injuries of head, neck, thorax, abdomen, vessels and extremities resulting in severe polytrauma being the most common cause of death. Nevertheless, injury pattern may differ depending on age, fall height and victim´s intention to fall [16]. Due to the limited number of patients, the variety of patient age and both suicidal and accidental falls from height > 3 m, interpretation of our findings is limited. Further research is necessary to gain more insights in pediatric injury pattern related to accidental and suicidal falls. In our data, three adolescents died due to a fall from height > 3 m between 0 and 5 a.m. without a suicidal background being proven. Considering the frequency of suicides in this age group and the typical event times during night hours, suicides would still be conceivable.

5 out of 9 patients who died due to traumatic railway injury committed suicide, and 7 out of 9 patients were 14–18 years old. Fatal self-inflicted injury is one of the leading causes of death among young people. In our study, 17 patients committed suicide with 77% being male, age ranged from 14 to 18 years, with a mean age of 16 years. The results correspond to other studies, showing increased suicide rates during puberty [17] and among male adolescents [18]. Male suicidents tend to choose rather “violent” suicide methods with a higher risk of death, which might explain this gender discrepancy. Due to the focus on “trauma” in this study, causes of death such as “intoxication” which might be preferred by female suicidents were excluded from our analysis [18].

Eight patients were killed by third party violence, 7 of whom were younger than 13 years. Surprisingly, third party violent acts were responsible for 24% of fatal trauma between 0 and 13 years. Recognizing violence against children and its prevention remain great challenges. Global evidence reveals that the prevalence is highly underestimated [19,20,21]. Most of the children in our study were beaten to death, one died from a violence-related fall from height > 3 m, one 8-year-old girl bled to death due to a cut through the carotid artery and one 17-year-old boy died from a cardiac stab wound.

A relevant proportion of traumatic deaths occurred on-scene, i.e., before arriving at hospital (42%). This highlights once again that the pre-hospital setting remains a hot spot of trauma mortality [7].

Data analysis regarding potential preventable trauma deaths was not performed in the presented study. Some cases in the age group of 0–6 years suggest that a neglect of adequate supervision may have contributed to fatal accidents, this should be further analysed in follow-up studies. Only autopsy reports of deceased children and adolescents were analyzed. Conclusions about non-fatal injury patterns and the incidence of non-fatal pediatric trauma events cannot be derived. Antunez et al. reported that perimortem full body computed tomography may be beneficial in identifying causes of death in children with severe trauma, futures studies should therefore also focus on radiological imaging [22]. autopsy rates are low in Germany, and even pediatric trauma fatalities do not always undergo forensic autopsy. Thus, there might be a bias between incidence of fatal pediatric trauma in a certain area and performed forensic autopsies in trauma death cases in that area. Besides, there is a second institution in Berlin which performs forensic autopsies, the State Institute of Forensic Medicine. Autopsy reports from this institution were not included in our study but should also account for about 70 pediatric death cases during the study period.