Use of "therapeutic complication" as a manner of death

Analyses of deaths due to therapeutic complications (TCs) provide important quality of care information for medical providers. In New York City, 463 deaths were investigated by the Office of Chief Medical Examiner and certified with TC as the manner of death in 2003. The TC manner of death is used for fatalities due to predictable complications of appropriate medical therapy. All death certificates and select autopsy, hospital, and investigation reports were reviewed. Data concerning cause of death, contributing conditions, age, race, and sex were extracted. The types of complications and the causes of death were classified into various types of surgical and nonsurgical categories of complications. These included: postoperative infections, pulmonary emboli, and technical and medication complications. The use of TC as a manner of death has benefits and limitations. Without the TC option, one is forced to certify certain deaths (e.g., penicillin anaphylaxis) either as natural or accident. The TC option allows easy identification and tracking of medical complications for public health purposes and also allows more consistent reporting of natural and medical-accidental deaths. In general, complications that occur during emergency surgeries/procedures for natural disease, tend to be certified with a natural manner. The "but for" test may be used to distinguish natural from TC deaths. There are criteria for distinguishing TC from accidents and homicides. TCs that occur during treatment of a potentially life-threatening injury, are superseded by the manner dictated by the circumstances of the initiating injury. The certification of TC usually does not address errors of omission, clinical judgement/management, or missed diagnoses.     

Operational criteria for the determination of suicide

Suicide is an important public health problem for which we have an inadequate public health database. In the United States, decisions about whether deaths are listed as suicides on death certificates are usually made by a coroner or medical examiner. These certification decisions are frequently marked by a lack of consistency and clarity, and laws and procedures for guiding these decisions vary from state to state and even from county to county. Without explicit criteria to aid in this decision making, coroners or medical examiners may be more susceptible to pressures from families or communities not to certify specific deaths as suicide. In addition, coroners or medical examiners may certify similar deaths differently at different times. The degree to which suicides may be underreported or misclassified is unknown. This makes it impossible to estimate accurately the number of deaths by suicide, to identify risk factors, or to plan and evaluate preventive interventions. To remedy these problems, a working group representing coroners, medical examiners, statisticians, and public health agencies developed operational criteria to assist in the determination of suicide. These criteria are based on a definition of suicide as "death arising from an act inflicted upon oneself with the intent to kill oneself." The purpose of these criteria is to improve the validity and reliability of suicide statistics by: (1) promoting consistent and uniform classifications; (2) making the criteria for decision making in death certification explicit; (3) increasing the amount of information used in decision making; (4) aiding certifiers in exercising their professional judgment; and (5) establishing common standards of practice for the determination of suicide.     

Why Do People Hang Themselves on Trees? An Evaluation of Suicidal Hangings on Trees in Konya,Turkey, between 2001 and 2008

Hanging is the most common method of suicide in the world, and many public places offer a means or opportunity to carry out the activity. Of 4,452 death examinations and autopsies, there were 378 (8.5%) suicides and suicide method was hanging in 185 (48.9%) cases. In 20 of these (10.8%), the suspension point was the branch of a tree. The incident location was the garden of the victim's house in nine cases, the woodlands in seven cases. The suicides were attributed to psychiatric disorders in nine cases, economic problems in six cases, and family problems in five cases. It is concluded that hanging on a tree as a suicide method is often committed by males and the underlying motive may be different in suicidal hangings on trees occurring at daytime and night. For preventional purposes, the reporting of such suicides in public places by the media may be restricted by local authorities.     

The problem of determining the manner of death as suicide or accident in borderline cases

The purpose of this study was to check the reliability of the classification of death in cases regarded primarily as accidents or undetermined. The material used for the analysis consisted of the documents of autopsies performed at our department in 1981. There were altogether 283 cases of suicides, accidents or undetermined deaths, accounting for 8.4% of total mortality, and of these 180 cases were of the two last categories. In 125 cases primarily regarded as non-suicides (accidents or undetermined) there were some features of suicide leading to reclassification as probable suicide in 24 cases. Fifteen of these were primarily poisoning "accidents", mainly alcohol intoxications. The result indicates that the suicide rate would be 3.7% instead of 3.0% of the total mortality. It may thus be concluded that the official figure for suicides could be as much as 18.9% smaller than the "actual" figure.     

Natural,Unexpected Deaths: Reliability of a Presumptive Diagnosis*

Abstract: We retrospectively analyzed 100 deaths because of suspicions and concerns expressed by the family. We compared the preautopsy cause of death, as determined by a thorough review of the clinical data and circumstances, to the autopsy‐derived cause of death. In the majority (91/100), the preautopsy and postautopsy proximate causes of death were in agreement. In 9%, the autopsy provided information that resulted in a proximate cause of death different than anticipated. In four instances, the manner of death also was incorrect and was determined to be an accident rather than the originally presumed natural. No homicide or suicide would have been misclassified. In another nine instances, where the premortem and postmortem proximate causes of death were in agreement, the autopsy provided a specific mechanism of death. With a quality initial medicolegal death investigation, a subset of sudden deaths in adults may be reliably certified without an autopsy.     

Suicidal electrocution in Sydney: a 10-year case review

A retrospective study was undertaken of all cases of death due to suicidal electrocution in Sydney, Australia between 1996 and 2005. A total of 25 cases were identified with 20 cases (80%) as a result of direct attachment to an electrical outlet and five cases (20%) as a result of immersion in a body of water with an electrical appliance. Twenty of the 25 individuals were men (mean age = 57 years, range 22-90) and five were women (mean age 67, range 53-88). At least 35% of decedents were either currently working or had worked as electricians. Electrical timers had been used in eight (32%) cases, the fuse blown in one case, but the remaining 16 (64%) bodies were "live" on arrival of witnesses or electricity personnel. This study demonstrates the phenomenon of electrical suicide as a regular occurrence in Sydney. We highlight the need for investigators and emergency workers to remain vigilant upon discovery of electrical suicides, due to the fact that most bodies remain electrically active after death.     

Asphyxial games in children and adolescents

Asphyxial games, as played by young adolescents, and going by various names, are not new phenomena. What seems to be different at present is an increase in lethality introduced by the increasing use of ligatures and "playing" the game alone. The authors present a properly certified but insufficiently appreciated case followed 2 years later by 2 closely spaced but unrelated deaths in young adolescent males that made known this practice in New Hampshire youth. Other cases presented to the author from other jurisdictions are reviewed in aggregate. Presented are characteristics of victims of this practice that may help distinguish these deaths from suicidal asphyxia. A relative paucity of literature regarding asphyxial games outside the realm of autoerotic asphyxia gives rise to certification difficulties given the high prevalence of youth suicide.     

Complex Suicide by Self‐stabbing and Drowning: A Case Report and a Review of Literature

Sharp force injuries and drowning are methods exceptionally combined in complex suicides. We report a challenging case of complex suicide by self‐stabbing and drowning that illustrates the difficulty in discriminating between homicide and suicide in such circumstances of death. The corpse of a young man was found submerged in a river, stabbed nine times with two wounds that had penetrated the thorax and had caused lung injuries and a hemopneumothorax. The postmortem and histological examinations were consistent with a death caused by drowning, but the manner of death still remained undetermined. Police investigation finally concluded to a suicide, although no suicide note had been left and the victim had no underlying diagnosed mental disorder. The parameters that may help distinguish suicide from homicide at the autopsy should be interpreted in light of a thorough forensic investigation to determine the exact manner of death in such a case.     

Clinical and forensic indicators of "suicide by cop"

This paper reviews the literature pertaining to the phenomenon of "suicide by cop"--any incident in which a suicidal individual attempts to get law enforcement to kill him. This article defines the term "suicide by cop," discusses the various motivations of individuals who engage in this type of behavior, presents the risk factors and indicators for suicide and violence, and describes specific indicators for suicide by cop. Proper recognition of these events, prior and subsequent to their occurrence, has important implications for prevention, officer safety, equivocal death analysis and psychological autopsy, civil litigation, criminal justice proceedings, and community stability. This paper presents seven case studies which demonstrate the clinical and forensic indicators of this phenomenon.     

Suicidal hanging on high-voltage line pylon

Hanging is one of the most frequent methods for suicides among young males. This report presents two cases of suicide by hanging on pylons carrying high-voltage power lines. The male victims suffered electrocution while committing suicide. Electrocution was the cause of death in both cases, however in one case blunt force injuries from hanging contributed to death. In these two cases hanging was the intentional method of suicide and it was followed by electrocution. The cases demonstrate that scene investigation, a detailed autopsy with histology, and amamnestic data are essential in the evaluation of suicides by hanging and that the determination of the cause of death remains a challenge in investigating such cases.     

The insanity defense to suicide

The certification of suicide as the manner of death can result in either the complete loss or a significant reduction in life insurance benefits to the victim's survivors. It is, thus, not uncommon for these beneficiaries to contest suicide as the manner of death. Insanity is a recognized defense in law against suicide. It is recognized in law that, in some cases, an insane man cannot intentionally destroy himself. However, it is also recognized that life insurers can exclude suicide by an insane man from coverage. This article discusses the common law doctrines upon which the insanity defense to suicide is based, with references to judicial opinions from cases which involve contested suicides and the issue of insanity.     

Planned and unplanned complex suicides: a 5-year retrospective study

The notion of planned and unplanned complex suicides first appeared in 1974 by Marcinkowski and, since then, no systematic study of complex suicides has been published in the English forensic literature. Here, the authors present a 5-year retrospective study of complex suicides. Nineteen complex suicides were reviewed: five unplanned and 14 planned, including the first case of an unplanned complex suicide in a woman. All cases were analyzed in terms of gender, age, methods of suicide, the presence of a suicide note, and past suicide attempts, and statistically compared with a 50-case sample of simple suicides. A further comparison was established with compiled data from the literature. Similarities were revealed regarding incidence of complex suicides, male gender predominance, and types of methods used. In contrast, results showed a higher average age for planned complex suicide victims. Finally, the authors discuss the application of the complex suicide definition.     

Subway Train‐Related Fatalities in New York City: Accident versus Suicide*

Abstract: We examined the characteristics of subway train‐related fatalities in New York City between Jan. 1, 2003 and May 31, 2007 in order to determine which factors are useful in differentiating accident from suicide. Subway train‐related deaths with homicide and undetermined manners also are included. During this period, there were 211 subway train‐related fatalities. The manners of death were: suicide (n = 111), accident (n = 76), undetermined (n = 20), and homicide (n = 4). The causes of death were blunt trauma (n = 206) and electrocution (n = 5). Torso transection and extremity amputation were more frequent in suicides. Antidepressant medications were more frequently detected in suicides, whereas cocaine and ethanol were more frequent in accidents. However, autopsy findings should be weighed in the context of the entire evaluation along with other circumstantial and investigative findings. In unwitnessed deaths where additional information is unavailable or discrepant, the most appropriate manner of death usually is undetermined.     

Suicide by Medication Overdose in Prison: A Study of Three Cases

Suicide is one of the principal causes of mortality in a prison environment. Although suicide by medication overdose is less frequent than suicide by hanging, self‐strangulation, or vein cutting, it raises questions as to how the medications are obtained, particularly in view of the specific organization of the medication circuit in prisons. We present three cases of suicide by medication overdose involving different therapeutic classes with different distribution circuits and review the regulatory requirements and the measures that could be taken to prevent such suicides.     

Unplanned Complex Suicide—A Consideration of Multiple Methods

Detailed death investigations are mandatory to find out the exact cause and manner in non‐natural deaths. In this reference, use of multiple methods in suicide poses a challenge for the investigators especially when the choice of methods to cause death is unplanned. There is an increased likelihood that doubts of homicide are raised in cases of unplanned complex suicides. A case of complex suicide is reported where the victim resorted to multiple methods to end his life, and what appeared to be an unplanned variant based on the death scene investigations. A meticulous crime scene examination, interviews of the victim's relatives and other witnesses, and a thorough autopsy are warranted to conclude on the cause and manner of death in all such cases.     

Level of agreement between opinions of medical examiner investigators and forensic pathologist medical examiners regarding the manner of death

To evaluate the level of agreement between medical examiner investigators' opinion of the manner of death and what the manner of death was as certified by forensic pathologist medical examiners (MEs), we reviewed the case records stored in a database of all deaths reported to the office of the medical examiner in Fulton County, Georgia. Of 15,771 deaths reported to the office during a 10-year period, a difference exists in 1908 cases. In 900 natural deaths, the investigators recorded 135 accident, 10 homicide, 10 suicide, and 745 undetermined manners of death. In 755 accidental deaths, the investigators recorded 16 natural, 8 homicide, 13 suicide, and 718 undetermined manners of death. In 107 homicides, the investigators recorded 12 natural, 8 accident, 0 suicide, and 87 undetermined manners of death. In 70 suicides, the investigators recorded 9 natural, 9 accident, 3 homicide, and 49 undetermined manners of death. In 61 deaths classified as undetermined, the investigators recorded 25 natural, 13 accident, 17 homicide, and 6 suicide manners of death. In 15 deaths, the discrepancy exists due to an apparent error in the database information. This study confirms a high concordance between investigator and ME opinion regarding manner of death but also documents the need for case review and autopsies by forensic pathologists to confirm the investigators' opinion of the manner of death, determine the manner of death when the investigator selects undetermined, and on occasion, refute the investigators' opinion regarding the manner of death.     

Martyrs’ Last Letters: Are They the Same as Suicide Notes?

Abstract: Of the 800,000 suicides worldwide every year, a small number fall under Emile Durkheim’s term of altruistic suicides. Study on martyrdom has been limited. There has to date, for example, been no systematic empirical study of martyr letters. We examined 33 letters of Korean self‐immolators, compared with 33 suicide notes of a matched sample of more common suicides. An analysis of intrapsychic factors (suicide as unbearable pain, psychopathology) and interpersonal factors (suicide as murderous impulses and need to escape) revealed that, although one can use the same psychological characteristics or dynamics to understand the deaths, the state of mind of martyrs is more extreme, such that the pain is reported to be even more unbearable. Yet, there are differences, such as there was no ambivalence in the altruistic notes. It is concluded that intrapsychic and interpersonal characteristics are central in understanding martyrs, probably equal to community or societal factors. More forensic study is, however, warranted.     

Suicidal Drug Overdoses in New Mexico: A 5‐year Retrospective Review

To better understand the changing toxicology trends in suicidal drug overdoses in the setting of an increased national trend of multidrug overdoses, a retrospective review of electronic records from New Mexico's Office of the Medical Investigator database was performed between 2008 and 2012 to assess the drug type and current risk factors in suicide deaths. Information on demographics, circumstances, suicide risk factors, toxicology findings, and death certificates was collected and analyzed. Three hundred and forty‐two suicide cases of suicide overdoses were identified. Decedents were predominantly female (61.8%). Scene investigation revealed risk factors including suicide ideation (47.4%), previous suicide attempts (38%), and suicide note (38%). Psychiatric illness was present in 72% of cases, with depression being the most common illness. Chronic pain was seen in 27.2% of cases. Most deaths were attributed to multiple drugs (76%). Utilizing the toxicology information will assist in creating public awareness and provide a framework to support targeted efforts to attempt to prevent future suicides.     

Discrepancies in Death Certificates,Public Health Registries,and Judicial Determinations in Italy

The death certificate is mandated by civil law and serves as a medical‐scientific document useful for biostatistics and epidemiological research. For a variety of reasons, death certificates can be misclassified. We reviewed data from self‐inflicted deaths collected over an 8‐year period by the Forensic Institute of the University Sacro Cuore of Rome (Italy). Four hundred and thirty‐five of 2904 were classified as self‐inflicted deaths (15%). The comparison with death certificates processed by the local public health authority (ASL) and by the Italian National Census Bureau (Istat) and with the judicial investigation results available in the Italian Penal Court archive shows some discrepancies. One‐hundred and twenty‐four of 435 deaths were not considered to be self‐inflicted but due to a crime (29% overrecording suicide) with a higher reduction for women, suggesting that it is easier to confuse a murder for suicide in female cases. Any discrepancies between the mortality and crime data are discussed in details.