To examine the characteristic features of fatal food asphyxia and to develop an autopsy approach to such cases a retrospective study of autopsy files was undertaken at Forensic Science SA (Adelaide, Australia) over a 10 year period from 1993 to 2002 for all cases of food asphyxia/café coronary syndrome. Forty-four cases were identified (M;F=21:23), with one infant (11 mths) and 43 adults (30-96 yrs; mean 68.9 yrs), with a preponderance of victims (57%) aged between 71 and 90 yrs. Deaths occurred in nursing homes (N=22) cases, at home (N=11) and in restaurants (N=4). Twenty-seven of the victims (61%) had histories of neurological or psychiatric disorders such as dementia (N=8), schizophrenia (N=6), Alzheimer disease (N=4), atherosclerotic cerebrovascular disease (N=4), mental impairment (N=2), multiple sclerosis (N=1), Parkinson disease (N=1) and obsessive-compulsive disorder (N=1). Twenty-seven cases (61%) were described as either edentulous or having significant numbers of teeth missing. Toxicological evaluation of blood revealed alcohol and a variety of psychotropic prescription medications in 19 cases. Sudden collapse during or shortly after a meal should always raise the possibility of café coronary and the autopsy examination should not only attempt to demonstrate airway occlusion by a bolus of food, but also to identify or exclude underlying neurological disease. Such cases may raise issues concerning adequacy of care and appropriateness of medication. The diagnosis of café coronary syndrome can only be made with confidence after the clinical history and circumstances of death have been clearly established, impacted material has been demonstrated in the airway at autopsy (or recorded by those attempting resuscitation), risk factors have been identified and other possible causes of death have been excluded.