Abstract BACKGROUND: Pedestrians are the most vulnerable road users and represent 10-25 % of people killed in motor vehicle accidents (MVAs) in various parts of the world. The mortality rate has declined substantially in the western world due to improvements in road safety, but in order to facilitate a further reduction, better understanding of the circumstances of the fatal accidents, including the injury mechanisms and causes of death, is fundamental. OBJECTIVE: The purpose of this study is to identify deaths among pedestrians in South-Eastern Norway in the time period 2000-2014. We wanted to get more knowledge about which pedestrians in city traffic were hit by motor vehicles, and thus consider what can be done to prevent future deaths of pedestrians. The second purpose of our study is to see if it is possible to identify the mechanism and severity of the injuries. We also wanted to assess whether our study could be used to reconstruct an unknown pattern in future criminal cases. METHODS: We have studied pedestrians killed in MVAs in South-East Norway in the years 2000-2014. The study method was retrospectively to identify pedestrian fatalities through a search in the medical file system at the Institute of Public Health, and subsequently collect data from autopsy files and co-existent police reports. RESULTS: In total, 199 cases (M/F 111/88) were identified within the 15 years period. The median age was 58, and 32,7% were more than 75 years of age. Most accidents occurred at daytime. In weekdays there were more pedestrians killed in age 55 and above (65,1 % - 95/146) and in weekends there were most pedestrians killed in age group 35-54 (28,3 % -15/53). Most of the pedestrian deaths occurred when crossing the road (76,4 % – 97/127). There were 44,9 % (57/127) fatalities at crosswalks, and 31,5 % (40/127) crossing the road without crosswalk. More than half of the vehicles involved were passenger cars. In most cases there were good driving conditions, with clear visibility (82,1 % - 128/156), daylight (54,8 % – 92/168) and dry weather (69,2 % - 108/156) but the pavement was wet/slick/icy pavement occurred frequently (56,9 % - 91/160). Head injuries and multiple injuries were the cause of death in 71,9 % (143/199) of the cases, and intracranial head injuries were detected at autopsy in totally 76,9 % of the cases. Any type of lower leg fracture were present in 35,2 %. Blood alcohol levels higher than 0,5 g/l were detected in 21,6 % of the pedestrian fatalities. CONCLUSION: The present study findings show that a large proportion of fatal pedestrian accidents occur when older pedestrians are crossing the road during daytime. During weekends young male adults are overrepresented. Improved knowledge of injury mechanisms may be used to target future preventive measures in order to reduce pedestrian fatalities.