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Killed in action (KIA): an analysis of military personnel who died of their injuries before reaching a definitive medical treatment facility in Afghanistan (2004–2014)
  1. Stacey Webster1,2,
  2. E B G Barnard1,3,
  3. J E Smith1,
  4. M E R Marsden4,5 and
  5. C Wright1
  1. 1Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research and Academia), Birmingham, UK
  2. 2The 2nd Battalion Parachute Regiment, Colchester, UK
  3. 3Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
  4. 4Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine (Research and Academia), Birmingham, UK
  5. 5Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
  1. Correspondence to Capt Stacey Webster, Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research and Academia), Birmingham, United Kingdom; stacey.webster{at}


Introduction The majority of combat deaths occur before arrival at a medical treatment facility but no previous studies have comprehensively examined this phase of care.

Methods The UK Joint Theatre Trauma Registry was used to identify all UK military personnel who died in Afghanistan (2004–2014). These data were linked to non-medical tactical and operational records to provide an accurate timeline of events. Cause of death was determined from records taken at postmortem review. The primary objective was to report time between injury and death in those killed in action (KIA); secondary objectives included: reporting mortality at key North Atlantic Treaty Organisation timelines (0, 10, 60, 120 min), comparison of temporal lethality for different anatomical injuries and analysing trends in the case fatality rate (CFR).

Results 2413 UK personnel were injured in Afghanistan from 2004 to 2014; 448 died, with a CFR of 18.6%. 390 (87.1%) of these died prehospital (n=348 KIA, n=42 killed non-enemy action). Complete data were available for n=303 (87.1%) KIA: median Injury Severity Score 75.0 (IQR 55.5–75.0). The predominant mechanisms were improvised explosive device (n=166, 54.8%) and gunshot wound (n=96, 31.7%).

In the KIA cohort, the median time to death was 0.0 (IQR 0.0–21.8) min; 173 (57.1%) died immediately (0 min). At 10, 60 and 120 min post injury, 205 (67.7%), 277 (91.4%) and 300 (99.0%) casualties were dead, respectively. Whole body primary injury had the fastest mortality. Overall prehospital CFR improved throughout the period while in-hospital CFR remained constant.

Conclusion Over two-thirds of KIA deaths occurred within 10 min of injury. Improvement in the CFR in Afghanistan was predominantly in the prehospital phase.

  • trauma management
  • accident & emergency medicine
  • clinical governance
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  • Correction notice This article has been corrected since it appeared Online First. Corresponding author and address details have been added.

  • Contributors SW and CW initiated the idea, collected the data, analysed the results, wrote and reviewed the paper. EBGB analysed the results, wrote and reviewed the paper. MERM and JES wrote and reviewed the paper.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Anonymised data were supplied from the JTTR, and according to institutional agreement, ethical approval was not required. Permission to use postmortem data was obtained from the Oxfordshire Senior Coroner. The project was registered with the Academic Department of Military Emergency Medicine at the Royal Centre for Defence Medicine, Birmingham, UK—reference number: ADMEM2020/0001.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. Data has been collated from JTTR and Dstl databases.

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