A 3-year retrospective review of fatal carbon monoxide toxicity in the Western Cape, South Africa (2022–2024)

Charcoal burning (CB) in enclosed spaces has emerged as a recognised method of suicide due to the inhalation of lethal levels of carbon monoxide (CO). While this has been widely documented globally, CB is also implicated in accidental CO poisoning deaths, particularly in densely populated, low-income communities where limited access to safer heating, cooking, and lighting alternatives increases vulnerability and contributes to preventable fatalities. This retrospective study examined CO toxicity deaths unrelated to fire-burns in the Western Cape province of South Africa over a three-year period, from 2022 to 2024, focusing on prevalence, characteristics, and circumstantial patterns. A total of 68 postmortem cases were included from routine submissions to the Forensic Toxicology Unit in Cape Town. Of these, 50% were suspected accidents, 30.9% alleged suicides, and 19.1% remained under investigation. Most victims were male (69.1%), middle-aged (44.1%), and deaths peaked in winter ( p < 0.001), primarily driven by accidental exposures. CB was the most frequently identified source of CO, followed by vehicle exhaust and gullies/imbawulas (makeshift metal drums of combustible wood, coals, or refuse). The source of CO exposure was significantly associated with the suspected manner of death ( p < 0.001). The mean carboxyhaemoglobin (COHb) level was 60.7% (range: 31.4-78.4%) with significantly higher levels in suicides ( p < 0.001), while the mean blood alcohol concentration (BAC) was 0.07 g/100 mL (range: 0.01-0.26 g/100 mL). Most fatalities occurred in congested domestic settings within socio-economically disadvantaged areas, highlighting non-fire CO poisoning as an underrecognised public health concern. Prevention should include public education, housing safety improvements, warning labels, and greater access to safer energy sources. • Non-fire related carbon monoxide poisoning deaths in South Africa are understudied. • The first regional review of suicides and accidental deaths due to carbon monoxide poisoning. • Charcoal burning was the leading source of carbon monoxide in accidental fatalities. • Suicide deaths mostly involved vehicle exhaust fumes with higher carboxyhaemoglobin levels. • Carbon monoxide poisonings, primarily accidental, occurred most frequently in winter.