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.     

Empirical criteria for the determination of suicide manner of death

A 16-item instrument was constructed as a tool to assist medicolegal official in their investigations and certifications of suicidal deaths. The Empirical Criteria for the Determination of Suicide (ECDS)--derived from a combined set of the 22 criterion items of the Operational Criteria for the Determination of Suicide (OCDS) and 33 other items obtained from experts and the professional literature--was constructed and validated by using 126 suicide and accident cases obtained from 70 medical examiner participants. Analysis of the cases confirmed that suicide is a manner of death in which there is evidence of both self-infliction and intention to die. The 16 items retained in the ECDS discriminated suicides from accidents best in relation to self-infliction and intention. In analysis of its concurrent validity, the ECDS instrument predicted 100% of the suicides and 83% of the accidents, thus correctly identifying 92% of all cases.     

The use of mental status in death certification of suicide

A 5-year study (1982-1986) illustrates the use of mental status in death certification of suicide in 182 consecutive cases from Marion County, Oregon, U.S.A. The presence of specific mental illness was documented in Part II of the filed death certificate whenever sufficient data supported such a diagnosis. This study represents, so far as we are aware, the first use of mental illness in the routine death certification of suicide. The study subjects were described in terms of sex; age group; the presence or absence of a suicide note; the anatomical cause of death (Part I of the death certificate); and the presence of mental illness, severe physical illness, or alcohol abuse (Part II of the death certificate) as contributive to the death. About half (97 of 182 = 53.30%) of the study group was diagnosed as suffering from a major affective disorder. Another portion (18 of 182 = 9.89%) was classified as schizophrenic. A subgroup of 18 men, all of whom were residents of state mental or correctional institutions at the time of death, was also briefly described.     

Suicide squad: Boko Haram’s use of the female suicide bomber

Boko Haram first began using the tactic of suicide bombings in 2011 and in 2014 started using female suicide bombers. This research focuses on gender differences in the use of suicide bombers. The data were collected using open sources from June 16, 2011 to June 15, 2018. Using this longitudinal data, trends are described over that 7-year period, focusing on the use of females. A majority of the suicide bombings target civilians in Nigeria, Cameroon, Chad, and Niger. More than half of the bombers were women and girls, some as young as 7?years old, and there were more than 60 incidents where the bomber was below the age of 15. More female bombers were used to targets civilians, whereas men were used more often to target government, police, and military targets. Female suicide bombers were used in Cameroon, whereas males were used more often in Nigeria. Additionally, females used suicide belts or vests, whereas men carried out the overwhelming majority of vehicle-borne suicide bombings. In many cases, the use of the women as bombers involved coercion. The unprecedented use of female suicide bombers, particularly young girls, should be a focus of policy moving forward.     

Suicide by a locomotive with unusual transport of suicide victims

Two suicides are described in which the victims were transported for 400 m and 16 km (!) hanging from the locomotive's hook coupling. According to the Deutsche Bahn AG, it would be possible for a body caught on a coupling to be dragged for almost 600 km without being discovered. Upon discovery of such a body, the police must search long stretches of the railroad tracks.     

The manner and cause of death in a forensic series of chronic alcoholics.

Chronic alcoholics account for an increasing number of the cases which are examined in forensic pathology. The manner and cause of death in 122 chronic alcoholics is described and compared with a previous investigation and to a group of non-alcoholics. The percentage of cases in which the manner of death is undetermined is twice as high as in the control group, whilst the percentage of suicide, surprisingly enough is only half that of the control group. The patho-anatomic findings in the liver and the causes of death are discussed in detail.     

Suicide by hara-kiri: a series of four cases.

The authors describe four cases of suicide by hara-kiri. This very painful form of suicide consists of self-inflicting a wound in the abdomen using a sharp instrument. It was first reported in 988 A.D. in the East but has now become rare in both the East and West. These four cases occurred over a 40-year period in the Trieste and Bari medicolegal area. In two of our cases the victims were afflicted with mental illness, whereas the other two suffered from depression. In cases of death by hara-kiri, it is important to establish a differential diagnosis between suicide and homicide; the presence of trial wounds (inflicted by the victim as a form of practice to overcome any hesitation before stabbing the abdomen with the cutting weapon) can prove very helpful.     

Suicide with two guns represents a special type of combined suicide

Suicide by simultaneous gunshots with two firearms is rare. The case of a 90-year-old man who killed himself with two 6.35 mm pistols fired at the temples at the same time is presented. The victim was found dead on the terrace of his home; two guns and two cartridges were present near the corpse. Cases of suicides with two guns published in the literature are compared, and the Italian cases are illustrated briefly. The authors describe the circumstances and autopsy findings that permitted the assertion that it was a case of suicide and to exclude an homicide and show, by figures, the three-dimensional reconstruction of cranial shooting injuries. The use of two guns is considered a representation of a special type of "combined suicide" or "planned complex suicide."     

Autoerotic asphyxial death initially misinterpreted as suicide and a review of the literature.

Death during autoerotic activities is of special concern to law enforcement officials, medical examiners, the family of the decedent, and society in general. As in the probing of any violent demise, accurate identification, management, and preservation of all physical evidence; complete photographic documentation of the scene and the body; reconstruction of the scene; and interviews with the family and acquaintances (psychological autopsy) are mandatory for proper study, evaluation, and interpretation of the case. Because of a lack of knowledge on the part of many people, including professionals, about these activities and the fact that many autoerotic fatalities share common characteristics with suicide and homicide, these cases are often misinterpreted. The authors present a case of autoerotic accidental asphyxial death which was initially misinterpreted as suicide.     

A case of suicide disguised as natural death.

A case report describing the suicide of a physician classified initially as a natural death. Faced with the vehement protest of the family of the deceased the magistrate decided to request a 'preventive' forensic autopsy. Forensic investigations revealed the cause of death as being a pentobarbital intoxication and the circumstances favoured the hypothesis of a genuine suicide. This case illustrates that the tendency of magistrates to request or not an autopsy is related to their experience or intuition.     

Environmental hyperthermic infant and early childhood death: circumstances, pathologic changes, and manner of death.

Infant and early childhood death caused by environmental hyperthermia (fatal heat stroke) is a rare event, typically occurring in vehicles or beds. The aims of this study were to describe the demographics, circumstances, pathology, and manner of death in infants and young children who died of environmental hyperthermia and to compare these cases with those reported in the literature. Scene investigation, autopsy reports, and the microscopic slides of cases from three jurisdictions were reviewed. The subjects in 10 identified cases ranged in age from 53 days to 9 years. Eight were discovered in vehicles and 2 in beds. When the authors' cases were grouped with reported cases, the profile of those in vehicles differed from those in beds. The former were older, were exposed to rapidly reached higher temperatures, and often had more severe skin damage. The latter were mostly infants and were exposed to lower environmental temperatures. Hepatocellular necrosis and disseminated intravascular coagulation were reported in victims who survived at least 6 hours after the hyperthermic exposure. The consistent postmortem finding among nearly all victims was intrathoracic petechiae, suggesting terminal gasping in an attempt at autoresuscitation before death. The manner of death was either accident or homicide. Recommendations for the scene investigation are made.     

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.     

Suicide by the use of a chain saw

The paper describes a case of suicide by the use of a chain saw. Visceral and tissue damage caused by vibrations are documented in occupational medicine, but fatal damage is not often seen at autopsy. This paper gives an account of the damage to viscera and tissues that has been noted when strong vibrations of low frequency have been directed to the body for a very short time with fatal result after a few minutes survival time.     

Fire and suicide: a three-year study of self-immolation deaths.

Thirty-two self-immolation deaths by fire, representing about 1% of suicides, occurred in the province of Ontario (population 9 million), Canada, from 1986 through 1988. The victims, mostly male (male/female ratio, 26:6), were between 21 and 71 years old (mean age, 38 years). Although the scene of self-immolation was usually familiar to the deceased, some chose remote locations. Eleven were found dead in motor vehicles. An accelerant, usually gasoline, was used in most cases. Many of these individuals had, at some time, indicated their intent to commit suicide, a few by self-immolation, but only about half had a diagnosed psychiatric illness. Most of the victims had a reason to kill themselves, but the factors that motivated them to chose self-immolation by fire were uncertain. Fourteen individuals died in hospitals from severe burn complications. The remainder were found dead at the scene. The postmortem findings of soot in the airway and elevated carbon monoxide in the blood of most of these victims [the carboxyhemoglobin (COHb) concentration was in one case less than 10%, in ten cases greater than or equal to 10 to 50%, and in seven cases greater than 50%] were helpful in determining that the individuals were not only alive at the time of the fire but also that a significant number died from smoke inhalation and carbon monoxide poisoning. The highest levels of carbon monoxide were observed in victims discovered in motor vehicles.     

Suicide by hanging. A review of 56 cases

Fifty-six consecutive cases of suicide by hanging are reviewed. The data provide some evidence for associations between suicide by hanging and youth, incarceration, black males, and clustering. Evidence was noted of low incidence in females, rarity of white female hangings at home, a preference to hang oneself away from home if there have been previous suicide attempts, and possible seasonal trends which may differ from suicide overall. Thus, aside from the method chosen, hanging victims as a group displayed some differences from suicides in general.     

Childhood suicide: a report of four cases

A study of childhood suicide in individuals aged twelve years or less was performed on the case files of the Office of the Medical Examiner of Metropolitan Dade County in Miami, FL, over the eight-year period from 1977 to the present. Four cases were collected; these are presented in some detail. A discussion then ensues along with a review of pertinent literature concerning this phenomenon.