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Purpose This study aims to analyze the pattern of deaths in detention in Northern Tunisia as well as the causes of death. Design/methodology/approach The authors conducted a cross-sectional retrospective study including all the casualties of death in detention examined in the legal medicine Department in the main teaching hospital from 2005 to 2019. The department covers 10 out of the 11 governorates of Northern Tunisia and 13 prisons. Findings Of a total of 197 casualties, only 2 were females. The mean age was 45.39 ± 14.43 years. A known medical history was reported in 63.5%, mainly cardiovascular disease, mental health disorders and diabetes. Half of the deaths occurred at the hospital. A total of 53 victims spent less than one year in custody before their death. Most deaths occurred due to disease-related causes (78.7%; n = 155); among these, 69 victims died from cardiovascular disease. Suicide accounted for 3.6% of the casualties and homicides for four cases. Research limitations/implications Several missing data regarding the details of the detention circumstances as well as the absence in some cases of the toxicological and histopathology analysis results, which could bias the study findings. Practical implications Death in detention in Northern Tunisia involved mainly males between their 30s and their 50s who died mainly from cardiovascular or pulmonary disease. These results underscore the importance of empowering the penitentiary health system. Originality/value To the best of the authors’ knowledge, this study is one of largest studies with regard to the number of decedents and the number of prisons from the Arab countries allowing to draw a pattern of casualties of death in prison.