Late-Onset Vitamin K Deficiency Bleeding in Four Infants: A Forensic Pathology Case Series With Clinical–Autopsy Correlation

Late-onset vitamin K deficiency bleeding (VKDB) remains a preventable cause of catastrophic intracranial hemorrhage in early infancy, yet continues to present complex medicolegal challenges where parental refusal of prophylactic vitamin K persists. We present four infant deaths evaluated within the Turkish medico-legal system, each lacking prophylactic vitamin K at birth, in which autopsy played a critical role in excluding alternative causes and supporting findings most consistent with VKDB. Comprehensive review of clinical records and full forensic autopsies, including neuropathologic examination, demonstrated extensive multi-compartment intracranial hemorrhage with no findings sufficient to support inflicted trauma, skull fractures, vascular malformations, metabolic disease, congenital coagulopathy, or sepsis. Coagulation studies, when available, showed markedly prolonged prothrombin time/international normalized ratio and activated partial thromboplastin time, supporting acquired coagulopathy consistent with vitamin K deficiency. In all cases, postmortem findings aligned with clinical deterioration characterized by rapidly progressive neurologic decline. The circumstances surrounding refusal of prophylaxis, delayed medical presentation, and progression to fatal hemorrhage were evaluated in the context of medicolegal responsibilities regarding caregiver decision-making and cause-of-death certification. These cases underscore the critical role of forensic pathology in differentiating VKDB from non-accidental trauma and other causes of infant intracranial hemorrhage, ensuring accurate death investigation, and informing medicolegal evaluation in preventable infant deaths.