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To characterize sudden or unnatural deaths with very high-range blood alcohol concentrations (BACs) presenting to the Department of Forensic Medicine (DOFM) in Sydney between 1 January 1997 and 31 December 2011.Case series.Sydney, Australia.A total of 263 cases of sudden or unnatural death with a BAC of ≥0.300 g/100 ml.Case characteristics, circumstances of death, quantitative toxicology, major autopsy findings and serology.The mean age of decedents was 46.7 years and 74.5% were male. Pre-existing alcohol problems were noted in 78.7%. Deaths were due to alcohol toxicity/chronic alcoholism (35.0%), combined alcohol/other drug toxicity (14.8%), accidents (18.6%), natural disease (13.3%), suicide (11.0%), homicide (6.8%) and one case was undetermined. Alcohol was a direct, or contributory, cause of death in 84.4% of cases. The overwhelming majority (81.4%) occurred in a home environment, and deaths did not vary by day or month. The mean BAC was 0.371 g/100 ml (range 0.300–0.820 g/100 ml), being highest in alcohol toxicity/chronic alcoholism cases (0.410 g/100 ml). The most frequently detected substances, other than alcohol, were benzodiazepines (31.9%) and opioids (12.9%). Alcohol-related disease was diagnosed in 62.9% of cases. Alcohol-related pathology was prevalent across all categories of death: severe steatosis (35.3%), cirrhosis (22.5%), chronic pancreatitis (15.3%), cardiomyopathy (9.4%) and cerebellar atrophy (9.0%).Unnatural deaths with very high-range alcohol concentrations extend well beyond direct toxicity, and alcohol is causal in most cases. Those at greatest risk are middle-aged males, with long histories of alcohol problems.