Background: Body stuffing, defined as the rapid ingestion of poorly wrapped illicit drugs to evade arrest, is associated with unpredictable and potentially fatal complications. Although both mechanical airway obstruction and drug exposure may be encountered, establishing the primary mechanism of death remains a major forensic challenge, particularly in deaths occurring during police custody.

Case presentation: We report the case of a man who died suddenly during police custody while being transported to hospital. External examination revealed facial congestion and superficial traumatic lesions, along with older self-inflicted scars. Medico-legal autopsy demonstrated complete obstruction of the glottic opening by a knotted plastic bag containing two Methylenedioxymethamphetamine (MDMA) tablets. Toxicological analyses were qualitative only and identified MDMA in blood, urine, and gastric contents, as well as Tetrahydrocannabinol limited to gastric contents. No quantitative drug concentrations were available to assess toxicity severity or lethality. The direct visualization of a foreign body firmly obstructing the glottis provides unequivocal anatomical evidence of fatal mechanical asphyxia. While MDMA exposure was documented, the absence of quantitative toxicological data precludes attribution of death to drug toxicity. At most, drug exposure may be considered a possible contributory condition, without demonstrable causal primacy.

Conclusion: This case demonstrates that mechanical airway obstruction may constitute a complete and sufficient cause of death in body stuffing, even in the presence of detectable drugs. It underscores the importance of meticulous airway examination, cautious interpretation of qualitative toxicology, and comprehensive medico-legal investigation in deaths occurring during police custody.

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