Aims To determine: (1) the characteristics of cases presenting to the Department of Forensic Medicine Sydney (1997–2013) with foreign body pulmonary embolization; (2) the extent and locations of embolization; and (3) the relationship between extent, and use of other injection sites, with pathology.

Design Analysis of consecutive case presentations with foreign body pulmonary embolization.

Setting/participants Sydney, Australia, with a total of 373 cases (271 males, 102 females).

Measurements Full autopsy reports, microscopy of tissue samples, and full toxicology. The extent and locations of embolization, inflammatory responses, clinical signs of pulmonary hypertension and signs of right‐sided heart failure were examined.

Findings Cases increased from three (1997) to 58 (2013). In 43.4%, foreign particles were moderate–abundant in extent. Cases with moderate–abundant emboli were more likely to have injection sites other than the cubital fossa [odds ratio (OR) = 2.4]. In 6.9% of cases emboli were also found in other organs. A foreign body inflammatory response was present in 45.3%, vascular scarring in 8.0%, signs of pulmonary hypertension in 10.2% and signs of right‐sided heart pathology in 5.4%. Cases with moderate–abundant deposition were more likely to have emboli in other organs (OR = 7.9), a foreign body inflammatory response (OR = 5.3), vascular scarring (OR = 3.4), signs of pulmonary hypertension (OR = 5.4) and right‐sided heart pathology (OR = 5.3).