Unusual Elevator-Related Deaths: A Report of Two Cases

We present two cases of elevator-related deaths that occurred in two different elevators, and deaths were caused by a similar, but unusual, mechanism. An elevator is a platform or compartment housed in a shaft for raising and lowering people or things to different levels. Elevator-related deaths and injuries are rarely reported in the literature. In most of these cases, cause of death was attributed to falls. It seems that most of the elevator accidents may be attributed to factors related to device maintenance inadequacies or even to device malfunctioning. In our cases, both elevator cars were not equipped with full-length inner doors, thus allowing both accidents to occur. Since 2014, the European Union adopted a relative directive, which imposes the need to equip all elevators with such full-length doors. The enforcement of the above-mentioned EU Directive is crucial, in order to prevent similar accidents in the future.     

Pneumomediastinum and Soft Tissue Emphysema in Pediatric Hanging

Postmortem computed tomography (CT) is increasingly being used as a tool in forensic pathology. The exact value of postmortem imaging in detecting specific conditions has not yet been established, but in specific cases, it can be used as a diagnostic tool demonstrating findings that remain undetected during autopsy, as in this case. Pneumomediastinum and soft tissue emphysema were detected with postmortem CT in a 3‐year‐old girl after hanging. It was not found during autopsy. This radiological finding matches 3 adult cases previously described. It is assumed that in this case, the first reported in a child, hanging was the most likely cause as well. In the adult cases, it was interpreted as a vital sign; the person must have been alive to create a pressure gradient causing rupture of the alveoli. This case demonstrates one of the added values of postmortem imaging, the possibility of demonstrating findings that remain undetected during autopsy.     

Accidental Hanging Deaths in Children in Konya,Turkey Between 1998 and 2007*

Abstract: In general, hanging cases are the result of suicide, and accidental and homicidal hanging cases are rarely seen. This study retrospectively investigated 4571 death examinations and autopsies that were performed at The Konya Branch of the Forensic Medicine Council (Turkey) between 1998 and 2007; hanging was involved in 201 (6.5%) of the cases. There were a total of 13 accidental hanging cases, where 12 of these involved children. In seven of the cases, the accidental hanging involved a scarf that wraps around swing‐like cradles and is intended to prevent infants from falling down. It was concluded that accidental hanging deaths can be reduced by replacing swing‐like cradles with cribs that are designed for children, removing ropes in and around the house, and preventing children from reaching and/or playing with rope‐like objects.     

Double Hanging with Single Ligature: An Unusual Method in Suicide Pact

A married casual labor couple was found hanging in their makeshift bedroom with each end of a single chunni (a cloth worn around the neck by Indian women) spread across an iron bar below the roof. They left their two children, daughter, and son of 4 and 3 yrs age, respectively, with their grandmother living separately nearby, and went to attend cremation of one of their relatives. They returned late in the evening and found hanging in their bedroom next morning by neighbors.     

Observed Characteristics of Suicidal Hangings: An 11-year Retrospective Review

Many studies have been published regarding suicidal hanging deaths, and most forensic pathologists and coroners are very familiar with such causes of death. Forensic pathologists are challenged over their rulings regarding manner of death in part because the general public has a limited scope of knowledge. One such challenge centers on the question of whether a hanging can be a suicide if the individual is not fully suspended. The authors designed a retrospective study to review suspension in hangings and to analyze other criteria used to help in deciding manner of death. We examined 229 suicidal hanging deaths over an 11-year period (1997 through early 2009) using the data from two separate jurisdictions in Ohio. In conclusion, we found that the vast majority (83.4%) of people who hanged themselves were found partially suspended. Among other criteria analyzed, only the presence of petechial hemorrhages and acute neck injury was statistically significant.     

Sudden Cardiac Deaths in Adults with Congenital Heart Disease with Structural Abnormalities: A Retrospective Review of Cases in the Cook County Medical Examiner's Office

Sudden cardiac death is a significant cause of mortality in adults with congenital heart disease (CHD). The Cook County Medical Examiner's Office database was queried for cases of CHD as a cause of death in the period between July 2008 and April 2019. Twenty-two cases were identified, including 11 decedents with simple defects and 10 decedents with complex defects. All of the subjects were in apparent good health at the time of death. In the absence of other obvious causes of death, simple defects were considered cases of sudden cardiac death. Significant cardiac morphological changes were common in complex defects. While 16 cases had known, diagnosed/treated CHD, 5 cases had no diagnosis prior to autopsy. In these cases, the ability to recognize CHD (sometimes subtle) helped in determining the causes of death. Therefore, forensic pathologists must be able to properly recognize various forms of CHD and request consultations, when needed.     

Correcting the Count: Improving Vital Statistics Data Regarding Deaths Related to Obesity

Obesity can involve any organ system and compromise the overall health of an individual, including premature death. Despite the increased risk of death associated with being obese, obesity itself is infrequently indicated on the death certificate. We performed an audit of our records to identify how often “obesity” was listed on the death certificate to determine how our practices affected national mortality data collection regarding obesity‐related mortality. During the span of nearly 25 years, 0.2% of deaths were attributed to or contributed by obesity. Over the course of 5 years, 96% of selected natural deaths were likely underreported as being associated with obesity. We present an algorithm for certifiers to use to determine whether obesity should be listed on the death certificate and guidelines for certifying cases in which this is appropriate. Use of this algorithm will improve vital statistics concerning the role of obesity in causing or contributing to death.     

Hands Tied with Bag Full of Books in Suicidal Hanging

Hanging deaths associated with binding of limbs, masking of a face, and gagging are always suspicious. In suicidal hanging, the victim uses these added techniques to prevent him from backing out of his decision and to ensure death. However, binding of limbs and adding extra weight to the suspension in hanging are not reported. Herein, we report a case where the victim tied a bag containing books weighing 7 kg (15.4 lbs) to both his hands during hanging. The forensic specialist must be aware of the unusual presentation of suicidal hanging which may suggest foul play. The manner of death must be established after detailed analysis of circumstantial evidence, information obtained from the witnesses, complete autopsy, and toxicological examination.     

Methadone‐Related Deaths – Epidemiological,Pathohistological, and Toxicological Traits in 10‐year Retrospective Study in Vojvodina,Serbia

The number of methadone‐related deaths (MRDs) during a 10‐year period (2002–2011) in the region of Vojvodina, Serbia, was increased. The cases were evaluated according to epidemiological parameters, pathohistological findings, and toxicological screening. The majority of victims were men, aged from 20 to 38. Pathohistologically, the signs of acute focal myocardial damage were present in the heart of victims with drug abuse history shorter than 2 years, while both signs of recent and chronic focal myocardial damage were developed among victims with longer drug abuse history (2–5 years). In postmortem blood samples of 54.84% of victims, methadone was detected in combination with diazepam, both in therapeutic range. Alcohol was absent in most cases. Other detected drugs were antipsychotics and antidepressants in therapeutic concentrations. These findings raise the attention to the concomitant use of methadone and benzodiazepines with the need for further studies to clarify the mechanism of death in such cases.     

Aortic Dissection and Sudden Unexpected Deaths: A Retrospective Study of 31 Forensic Autopsy Cases

Acute aortic dissection (AAD) is the most common cause of sudden unexpected death related to aortic diseases. A retrospective study of 31 sudden unexpected deaths caused by AAD was conducted at Xi'an Jiaotong University Forensic Center from 2001 to 2012. We summarized the forensic characteristics of AAD and assessed the clinically diagnostic accuracy of AAD. The characteristics of sudden unexpected death due to AAD were male predominant (male: female = 6.7:1), relatively young with the mean age of 44, and predominance of type A dissection (77.4%). Cardiac tamponade was the most frequent cause of sudden death (87.1%). Of the 31 cases, 26 (83.9%) patients were not recognized clinically and were misdiagnosed with acute myocardial infarction, coronary artery disease, cholecystitis, acute gastroenteritis, renal/urinary lithiasis, or acute pancreatitis. In summary, AAD can be difficult to recognize, diagnosis is therefore sometimes delayed or missed. The medicolegal death investigation can help physicians have a better understanding of AAD.     

Hypothermia-related Deaths: A 10-year Retrospective Study of Two Major Metropolitan Cities in the United States*

Hypothermia-related deaths affect vulnerable populations and are preventable. They account for the vast majority of weather-related deaths in the United States. The postmortem diagnosis of hypothermia can be challenging, as there are no pathognomonic signs. The electronic databases of the New York City Office of Chief Medical Examiner and Harris County Institute of Forensic Sciences were searched for all fatalities where the primary cause of death included hypothermia, between January 2009 and July 2019. There were 139 hypothermia deaths in New York City (NYC) with an average annualized rate of 1.7 per million. During this same time, there were 50 hypothermia deaths in Houston with an average annualized rate of 2.4 per million. Males were more likely to die of hypothermia compared to females in both cities. The rate ratio (RR) in NYC was 3.55 (95% CI 2.40, 5.25), while the RR in Houston was 2.83 (95% CI 1.50, 5.32). Age- and sex-specific standardized hypothermia mortality rates were 18.2 (95% CI 15.1, 21.2) per million in NYC and 30.1 (95% CI 21.7, 38.6) per million in Houston. The comparative hypothermia death ratio was 1.66 (95% CI 1.19, 2.30), indicating hypothermia mortality in Houston was 66% higher than in NYC. There was no correlation between zip code poverty rates and hypothermia-related deaths. The most consistent autopsy finding was Wischnewski spots (56.6%), and ethanol was the most common toxicological finding (36.5%). Local agencies can use this data to target these higher-risk populations and offer appropriate interventions to try to prevent these deaths.     

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.     

Agonal Sequences in Four Filmed Hangings: Analysis of Respiratory and Movement Responses to Asphyxia by Hanging*

Abstract: The human pathophysiology of asphyxia by hanging is still poorly understood, despite great advances in forensic science. In that context, filmed hangings may hold the key to answer questions regarding the sequence of events leading to death in human asphyxia. Four filmed hangings were analyzed. Rapid loss of consciousness was observed between 13 sec and 18 sec after onset of hanging, closely followed by convulsions (at 14–19 sec). A complex pattern of decerebration rigidity (19–21 sec in most cases), followed by a quick phase of decortication rigidity (1 min 00 sec–1 min 08 sec in most cases), an extended phase of decortication rigidity (1 min 04 sec–1 min 32 sec) and loss of muscle tone (1 min 38 sec–2 min 47 sec) was revealed. Very deep respiratory attempts started between 20 and 22 sec, the last respiratory attempt being detected between 2 min 00 sec and 2 min 04 sec. Despite differences in the types of hanging, this unique study reveals similarities that are further discussed.     

Lightning Deaths: A Retrospective Review of New Mexico's Cases, 1977–2009

To better understand lightning deaths, a retrospective review of electronic records from New Mexico's Office of the Medical Investigator database was performed between 1977 and 2009 to update and assess current risk factors. Information on demographics, circumstances, autopsy, and death certificates were collected and analyzed. Fifty‐four decedents were identified, ages 2–71 years old (mean 34 years old), 42 males and 12 females. Common racial/ethnic groups were non‐Hispanic Whites and American Indians (together comprising 72% of all cases). Physical findings were often related to the heat carried by the electrical current including clothing alterations (29.6%) and burning of skin (53.7%). Most deaths occurred on weekend afternoons in summer months, associated with recreational activities or agricultural work, and rural locations (77.8%). Utilizing the demographic information, clustered events, and associated outdoor activities will assist in creating public awareness and provide a framework to support targeted warnings in an attempt to prevent future deaths.     

Characterization of lesions in hanging deaths

Hanging is a common method of committing suicide and a routine task in medico-legal autopsies. The hanging mark is the most relevant external sign and its characteristics are well known, but, for unknown reasons, there are major differences in reports on internal findings. We retrospectively studied 228 consecutive cases of hanging deaths. A complete standard autopsy was performed for every case. We investigated the association between the characteristics of the hanging mark and the frequency of bone, cartilage, soft tissue, and vascular injuries with the mode of suspension. Most cases (75.3%) presented some kind of bone or cartilage fracture, but these were unrelated to any of the variables studied. Vascular lesions are clearly more infrequent: intimal injuries were found in the carotid artery (9.1%), the jugular vein (2.2%), and ruptures of the carotid adventitial layer (21.7%). These could be partially associated with the use of a hard fixed noose and body weight.     

The Interplay Between Diabetes and Pancreatitis: Two Case Reports of Sudden,Natural Deaths and a Review of the Literature

Diabetes mellitus (DM) is a common disease involving insulin resistance or deficit that, when left unchecked, may cause severe hyperglycemia and subsequent end‐organ damage. Acute pancreatitis (AP) is inflammation of the pancreas that can lead to significant morbidity and mortality. AP and DM both account for a significant amount of sudden deaths, and rarely both disease processes may be present in the same decedent, causing some difficulty in wording the cause of death statement. Although much research has been directed at studying the causes and risk factors for AP and DM, there is a complex interplay between these diseases that is not fully understood. This study presents two autopsy cases of sudden, natural deaths that illustrate this interplay, along with a review of the literature. An algorithm for differentiating AP and DM is then discussed in the context of the presented cases as a proposed aid for forensic pathologists in the certification of such deaths.     

A Retrospective Study of the Investigation of Homicidal Childhood Asphyxial Deaths

As one of the leading causes of traumatic deaths in newborns, infants, and young children, there is no anatomic or microscopic feature that is pathognomonic for asphyxial deaths. Instead, pathologists rely on investigation information, including confessions and/or witness statements, and potential evidence at the scene. Twenty cases of homicidal newborn, infant, and young children asphyxial deaths were reviewed, which included death and police investigation reports and autopsy reports, as well as histology slides of lung sections. This series of homicidal asphyxial deaths highlight that, in a vast majority of such cases, the final cause and manner of death rulings are dependent on confession by the perpetrator. Furthermore, this series highlights the possible role of histology to help forensic pathologists better certify asphyxial deaths. Finally, this series emphasizes important investigation points and considerations at autopsy during the investigation of asphyxial deaths in newborns, infants, and young children.     

Planned Complex Occupation‐related Suicide by Captive‐bolt Gunshot and Hanging*

Abstract: Planned complex suicides are committed by using two or more previously planned methods simultaneously to make sure that death will occur even if one method fails. Herein, we presented a case of occupation‐related planned complex suicide, committed by captive‐bolt gunshot and hanging. A 29‐year‐old man, who worked as a butcher, was found dead in the stable, hanging by the neck with a captive‐bolt gun embedded in the forehead region of his head. The hanging was complete. Along the bolt canal were bone fragments, and at the end of the path was the punched‐out fragment of the skin and soft tissue. There were no fractures of the hyoid bone and laryngeal cartilages, and a superficial hemorrhage was present in the right sternocleidomastoid muscle. Our case underlines the utility of forensic autopsy and death scene investigation in reconstructing the mechanism of death, as well as the dynamics of the event.     

The Role of Postmortem Computed Tomography in the Evaluation of Strangulation Deaths

We explored the value of postmortem computed tomography (PMCT) to augment autopsy in evaluating strangulation fatalities. A literature search identified 16 studies describing autopsy findings in 576 deaths and two studies describing autopsy and PMCT findings in six deaths. Similar cases were identified from our institution, yielding 130 deaths with autopsy findings and 14 deaths with both autopsy and PMCT findings. The presence of laryngohyoid fracture and soft tissue hemorrhage was compared from autopsy and autopsy+PMCT cases. The detection rates of fractures in autopsy and autopsy+PMCT cases were not significantly different. PMCT identified all fractures observed at autopsy and five fractures not identified. While PMCT may not detect soft tissue injuries in decomposed remains or subtle internal hemorrhages in neck injury, it is equally able to detect bony injuries as autopsy and might surpass autopsy in detecting subtle fractures. We conclude PMCT is useful to supplement autopsy in strangulation cases.     

Self‐Strangulation Turning into Partial Hanging for a Suicide Victim

Hanging is the most common asphyxial method of suicide, whereas suicide by strangulation is unusual. Here, we are reporting a particular methodology of the asphyxial method of suicide in which a case of self‐strangulation culminated into partial hanging. A 30‐year‐old male wrapped one end of the cable wire around his neck. He then passed the other end over a curtain rod and tied that end around the right hand. He pulled the hand down, using the curtain rod as a fulcrum, to tighten the noose around the neck in an attempt to strangulate himself. However, he lost consciousness during the process and the body slipped down, pulling the right hand up which got stuck at the curtain rod. This led the body hanged in the kneeling position. This bizarre scenario raised suspicion of homicide but the crime scene, autopsy and victim characteristics were in favor of suicide.