Undetermined Manner of Death: An Autopsy Series

A manner of death may be ruled undetermined by the forensic pathologist when there is insufficient information about the circumstances surrounding the death to make a ruling. The aim of our study was to retrospectively analyze a series of autopsy cases that were classified as undetermined manner of death after complete investigations. In all, 48 cases were examined. In 23 cases (48%), the cause of death was determined. The most frequent cause of death was toxic death (n = 11). More than one manner of death was deemed conceivable for most cases (n = 39). The most frequent and the most probable manner of death was accident (n = 37). Homicide was not excluded in about 23% of the cases. Our study showed that the manner of death may remain undetermined despite an established cause of death, and even when two or more conceivable causes of death are considered. Our study pointed out that undetermined manner of death covers a wide range of situations and that homicide may be underestimated.     

Stressful events as a trigger of sudden death: a study of 43 medico-legal autopsy cases

The reports relating emotional stress to sudden death are largely anecdotal. In addition to experimental and electrophysiological studies, an opportunity for a better understanding of possible stress-related sudden death (SSD) may be provided by medico-legal autopsies. The goal of our autopsy study was to analyze cardiovascular pathologic findings in cases of SSD and if possible identify mechanisms by which the stressful event (SE) could be the cause. Forty three cases were studied (29 males and 14 females). In all cases, the SE and the death were witnessed. The age range was 22 to 90 years in males (mean, 52) and 30 to 92 years in females (mean, 64). Death occurred in all cases without premonitory symptoms. In 20 cases, death occurred during the SE and in the other 23 cases occurred within 2 h of the event. SE included fear, 15 cases; altercation, 21 cases; sexual activity, 3 cases; police questioning or arrest, 4 cases. According to police reports, in 40 cases (90%), the victims had no previous clinical history of cardiovascular disease. At autopsy, the heart weight in males ranged from 255 to 1000 g with a mean of 517 g and in females the range was 250–700 g with a mean of 417 g. In only 3 cases, gross and microscopic examination of the heart was normal. In 2 of the remaining 40 cases the subjects died of subarachnoid hemorrhage. In 38 cases, a cardiac cause of death was found as follows: coronary heart disease, 27 cases; cardiomyopathy, 6 cases; aortic valvular stenosis, 2 cases and right ventricular dysplasia, 3 cases. A coronary artery thrombosis was found in 8 cases of sudden coronary death. Post myocardial infarction fibrosis was present in 25 cases (92%) of sudden coronary death. In conclusion, it appears from our autopsy study that SSD occurs primarily in those individuals with severe heart disease, especially coronary heart disease.     

Toxicologic analysis in cases of possible sudden infant death syndrome: a worthwhile exercise?

The diagnosis of sudden infant death syndrome (SIDS) is one of exclusion. At the Department of Forensic Medicine, Westmead Hospital, toxicologic analysis is performed as part of the postmortem examination of all apparent SIDS deaths. The results for the 5-year period January 1, 1994, to December 31, 1999, were audited to determine whether such routine testing was worthwhile. During this time there were 117 cases with a history consistent with SIDS. Drugs were detected in 19 (16%) of these cases. In 1 case, death was attributed to the finding of methadone. The presence of methadone was regarded as a possible contributing factor to death in a further 2 cases. The presence of possible methadone toxicity had not been expected from the history given before the examination in these 3 cases. In 114 cases there was a suitable sample for alcohol testing; in no case was alcohol detected. In 13 cases the postmortem examination revealed an anatomic cause of death (including 3 cases consistent with whiplash/shaken baby/impact head injury), which excluded a diagnosis of SIDS. In conclusion, routine toxicologic testing in all possible cases of SIDS death supplements the postmortem examination in excluding cases of non-SIDS.     

Screening of milk aspiration in 105 infant death cases by immunostaining with anti-human alpha-lactalbumin antibody.

To determine the frequency and degree of milk aspiration in infant death cases, immunohistochemical examinations were performed on lung sections from 41 sudden death cases and 64 in-hospital death cases using anti-human alpha-lactalbumin antibody. Milk aspiration to some degree was detected in more than half of the sudden death cases and in about one-third of the in-hospital death cases. A semi-quantitative examination of the amount of aspirated milk was subsequently performed in the positive cases. The amount of aspirated milk in the sudden death cases was significantly higher than that in the in-hospital death cases. The frequency distribution of the amount of aspirated milk was similar in shape in both groups. In most cases, a very small amount of aspirated milk was detected. The aspirated milk was assumed to be a result of occasional gastroesophageal reflux or cardiopulmonary resuscitation. However, in five cases, much larger amounts of aspirated milk were found. In these cases, milk aspiration may have been an important part of the cause of death. We concluded that slight milk aspiration is not rare in infant death cases, and that in a few cases, the aspiration is lethal. An immunohistochemical screening test is available to perform a postmortem diagnosis in these cases.     

Sudden Death Due to Hydatid Disease: A Six‐Year Study in the Northern Part of Tunisia

Human ecchinococcosis also known as hydatid disease is a zoonotic infection caused by the tapeworm Ecchinococcus with 2–3 Million cases worldwide. We hereby report a 6 years period study of Sudden death due to hydatidosis aiming to analyze the epidemiological criteria, death circumstances, and autopsy observations attributed to hydatid disease. During the past 6 years, 26 death cases were due to hydatid disease. Our analysis shows that the sex ratio (M/F) was 1.6, the mean age was 31‐year old, and 65% of the subjects lived in rural places. In 17 cases, death occurred in the victim's place, five victims died after a heavy exercise, and in two cases, death occurred immediately after trauma. At autopsy, 91% of the cysts were found in the liver. In three cases, death followed a septic state, and in two cases, it followed an acute respiratory failure. Death was attributed to anaphylaxis in 17 cases.     

The importance of medico-legal autopsies. An analysis of the complex problems regarding damages

One hundred forty-four medico-legal autopsies were performed at the University Institute of Forensic Medicine in Copenhagen during the period 1973-77, all requested by the National Office of Social Security in order to estimate whether the cause of death could be related to the work of the deceased. The total number of medico-legal autopsies in the same period was 4050. The material included only four women. One hundred seventeen men died during work, 26 cases were accepted. Clear cases of accidents were always accepted and damages were paid. In cases where the deceased died on his way to or from work damages were rejected. Nineteen men (13%) had died after returning to their homes. Two cases among these were accepted (fall from scaffolding during working hours, arsenic poisoning where death occurred later in hospital). The mean age of the group was about 50 years, which is less than in an average medico-legal population. In all cases but two the autopsy revealed the cause of death, i.e. that unknown causes of death totalled 1.4%. The manner of death was elucidated in all cases. The most frequent cause of death in men turned out to be coronary sclerosis and coronary thrombosis. All such cases were rejected as being due to working conditions, because in no case was extraordinary working stress found to be evident. The two cases of death which occurred at home showed the importance of being aware of injuries due to working conditions, even if death could not be directly related to an industrial accident.     

Evaluation of diagnostic tools applied in the examination of sudden unexpected deaths in infancy and early childhood

During the period between 1984 and 1999, 309 cases of sudden unexpected death in infancy and early childhood (0-3 years) were investigated at the Institute of Forensic Medicine in Oslo. In 73 cases, an explainable cause of death was found. In this non-sudden infant death syndrome (SIDS) group, 42 cases were due to disease, 14 to accidents, 7 to neglect/abuse and 10 cases were due to homicide. In 43 cases, there were pathological findings at the autopsy or suspect features in the history and/or circumstances, which were, however, insufficient to explain death ("borderline" SIDS). In the remaining 193 cases, nothing of significance was detected ("pure" SIDS).The purpose of the present study was to evaluate the importance of the different diagnostic tools used in diagnosing non-SIDS and borderline SIDS cases. The definition of SIDS requires a negative history as well as a negative autopsy result. Thus, the following variables were analysed: circumstances, medical history and autopsy, which included a gross pathological investigation, histology, neuropathology, microbiology, radiology and toxicology. In diagnosing deaths due to disease, histology, neuropathology and microbiology were the most important diagnostic tools. In contrast, information about the circumstances of death and the gross pathological findings at autopsy most often revealed the cause of death in accidents and cases of neglect/abuse and homicide.Following the drop in SIDS rate in Norway after 1989, the share of pure SIDS in proportion to the total population of sudden unexpected deaths in infancy and early childhood has decreased. The increasing proportion of non-SIDS and borderline SIDS cases presents a challenge to improve the quality of the investigation in cases of sudden death in infancy and early childhood.     

Tongue bite injuries--a diagnostic criterium for death in epileptic seizure?

Bite marks of the tongue are often associated with epileptic seizures, although information about the real frequency of bite marks of the tongue is hard to find. This is also true for their presence in deaths of epileptics or in deaths in general. The purpose of this investigation was to analyze the frequency of bite marks of the tongue in deaths of epileptics in comparison to a control group. Further points of interest were the spectrum of the causes of death recorded, toxicological data as well as the presence and localization of external head injuries. The study group consisted of 105 individuals with a known history of epilepsy, the control group of 107 individuals with sudden cardiac death. Autopsy reports were analyzed retrospectively. In the first group bite marks of the tongue were seen in 21% (in the subgroup "observed death during seizure" even in 64%) and were thus significantly more frequent than in the control group (2%). In 35 cases of the study material an unnatural manner of death was found (trauma, especially craniocerebral trauma, drowning, asphyxia, intoxication) and in 70 cases a natural death was assumed. However, in 41 of these the exact cause of death was not ascertainable. According to the SUDEP criteria (Ficker 2000, Nilsson 1999) 29 of these cases could be categorized as possible or probable SUDEP (sudden unexpected death in epilepsy) with 17 showing bite marks of the tongue. The fact that half of the remaining 12 cases showed bite marks of the tongue suggests at least for these cases that death occurred during the seizure. Head injuries were reported in 41% of the epilepsy group--in the subgroup "observed death during seizure" in 73%. Our investigation did not produce evidence for a higher frequency of bite marks of the tongue in cases in which resuscitation had been attempted. In our experience the presence of fresh bite marks of the tongue--according to histological findings--is a useful signs for the assignment of death to an epileptic seizure and especially for death during acute convulsion.     

Dog saliva transmitted pathogens as etiology of fatal infections (on the topic of causal relationship)

The authors report on 4 deaths. 3 of the victims had been bitten by dogs shortly before death; in one case the victim had close contacts with a dog. In 3 of the cases death was caused by septicemia; microorganisms occurring in the saliva of dogs, but rarely causing infection could be determined in 2 of the cases. While in case 1 there was no bite injury so that transmission must have occurred by droplet infection (without trauma) or via a discrete skin lesion, case 2 showed a penetrating dog-bite injury; in both cases the spleen had been surgically removed some years before. In case 3 a causal relationship had to be assumed between a dog bite and death, although no pathogen could be identified in microbiological tests. In case 4 death was not attributable to the dog-bite injury suffered, but was due to an internal pathological cause.     

Delayed death following strangulation (hanging)

6 cases of suicide by hanging with delayed death are presented in tables laying out the circumstances and the findings. All the persons involved remained continuously unconscious after initially successful reanimation; two were at this time already dead. The survival times lay between 18 hours and 4 days. In two cases intravital vertebral death occurred. In the other cases death was due indirectly to hypoxial brain-damage which had led to a greater or lesser extent to elective parenchymal necrosis. In 3 of 4 histologically investigated cases there was evidence of extensive cell destruction in the PCA muscle which was, however, not specifically related to the process of hanging since lesions of this nature also occur with other cases of delayed death after reanimation. In 7th case the problems encountered in compiling an expert opinion are discussed in cases where there are no corresponding procedural details. A 44 year old man died 3 weeks after having been submitted to bondage in a brothel at his own request (including binding of the neck). Compression of the throat with emphasis on one side was evident resulting in extensive ganglial cell damage in one half of the cerebral cortex.     

Features characteristic of homicide in cases of complete decapitation

Four cases of complete decapitation connected to homicidal acts are presented. In 3 cases, decapitation was inflicted postmortem after killing the victim. The motives for decapitation were considered defensive, aggressive, and a possible combination of the 2 in one case each. In one case, decapitation was a vital injury and accounted for death. In this case, an offensive motive for mutilation was suspected. The combination of death scene findings and autopsy results will in most cases distinguish between homicidal and other modes of death.     

Beta-hydroxybutyric acid--an indicator for an alcoholic ketoacidosis as cause of death in deceased alcohol abusers

We analyzed the postmortem blood of a total of 100 fatal cases for beta-hydroxybutyric acid (BHBA). In 25 cases of sudden and unexpected death of alcoholics we found pathologically increased levels of BHBA of 1260 to 47200 (median 8000) micromol/L. This led us to the diagnosis of an alcoholic ketoacidosis (AKA) as cause of death in these cases. The control group of 69 postmortem cases revealed that BHBA concentrations below 500 can be regarded as normal, and values up to 2500 micromol/L as elevated. Our study shows that BHBA values over 2500 micromol/L could lead to death, if no medical attention is sought. During storage we did not find any indication of postmortem formation or decomposition of BHBA in blood in vitro or in the corpses. In our opinion, BHBA should be considered the diagnostic marker of choice for the postmortem determination of alcoholic ketoacidosis (AKA) as the cause of death. The classical indications of such deaths are: unexpected death of a chronic alcoholic; none or only traces of ethanol in the blood; increased acetone blood concentration; and neither autopsy, histology, microbiology, nor toxicology reveal the cause of death. In six further cases a diabetic ketoacidosis (DKA) was diagnosed as the cause of death.     

Detection of medical examiner cases from review of cremation requests

Title 9, Chapter 19, Article 3 of the Arizona Administrative Code requires all bodies that are to be cremated must have the death certificate reviewed by a county medical examiner. In Tucson, AZ, and surrounding Pima County, all cremation requests are submitted to the Forensic Science Center, where the death certificates are reviewed by one of 5 board-certified forensic pathologists. In 2002, there were 5557 cremation requests, and in 2003 there were 5662 cremation requests. Of these requests, 670 (12.1%) and 447 (7.9%) death certificates were flagged for further investigation in 2002 and 2003, respectively. Eventually, 47 cases (0.8% of total, 7.0% of flagged cases) were accepted as medical examiner cases in 2002, and 43 cases (0.8% of total, 9.6% of flagged cases) were accepted as medical examiner cases in 2003. In 2002, the majority of cases were handled as a records review; however, 4 cases were brought in for autopsy and 1 was certified after an external examination only. In 2003, all cases were certified via a records review. The manner of death in all but 3 of these deaths was certified as accident, with complications of remote trauma being the most common proximate cause of death. The 3 most common injuries were complications of fractured pelvis or femur (15 in 2002, 22 in 2003), head injury due to fall (18 in 2002, 8 in 2003), and complications of remote motor vehicle accident (3 in 2002, 6 in 2003). The other 3 deaths included 2 homicides, 1 in each year, and 1 suicide in 2003.     

Neoplastic disease in a medicolegal autopsy material. A retrospective study in northern Sweden

Only a small fraction of sudden unexpected deaths are caused by neoplastic disease and thus subject ot medicolegal autopsy. The medicolegal autopsy forms an opportunity to study not only medically diagnosed and treated neoplasms, but also the natural evolution of untreated disease. In a series of 7,020 consecutive medicolegal autopsies in northern Sweden, we found 171 cases with malignant and/or intracranial neoplasms. In 41 cases, sudden death was caused by previously unknown tumors. The most common mechanisms of death in this group were disseminated cancer, intracranial tumors, pulmonary thromboembolism, hemoptysis, and aspiration of blood, and the most common locations were the bronchi and the lung. In some of these cases, the mechanism was sometimes dramatic, raising a question of violent death or intoxication. In 30 cases, sudden unexpected death was caused by previously known tumors, and also in this group disseminated cancer was the most common cause of death, and the most common locations were the bronchi and the lung. In 22 cases, tumors were found suicidal cases; in 14 of these, the tumor was considered to be a major causative factor to the suicide, while in eight cases the tumor was considered to be an incidental finding. The expected number of cancers in the 1,060 suicides investigated in this series was 27, according to the official cancer prevalence data. Thus, a possible over-representation of suicides among persons with cancer seems doubtful and needs further exploration.     

Cardiovascular abnormalities in children: a ten-year forensic pathologic study

In order to obtain information on types, incidence, and significance of cardiovascular abnormalities in children, a total of 104 consecutive medicolegal autopsies of children aged 8 days to 16 years during a 10-year period from May 1974 to April 1984 were studied. Extensive histological examination of the hearts was performed in 92 out of 104 cases and complemented with chemical and microbiological analyses. In the natural death group consisting of 53 children, 26 (49%) showed abnormalities: 7 (13%) malformations, 11 (21%) cardiomyopathies, 5 (9%) idiopathic subaortic hypertrophy, and 3 (7%) a heart weight only 50% of the expected weight. In the violent death ("control") group, abnormalities were found in 8 of 39 cases (21%), all of which were cardiomyopathy. Only 5 of 34 cardiovascular abnormalities (every 7th case), all complex malformations, were clinically recognized. In 14 (15%) of the total 92 examined cases the cardiovascular abnormality was the only apparent cause of death, and in 12 (13%) a contributing cause of sudden unexpected natural death, while in 3 (3%) it was related to a fatal accidental injury. In 5 (13%) of the 39 cases of violent death, cardiomyopathy was an incidental finding without any connection to the circumstances or cause of death. The causes of cardiovascular abnormalities were associated with bacterial and viral infections, respiratory disorders, phenytoin sensitivity, or were unknown. Because of the differences in diagnostic criteria employed by previous investigators, it cannot be determined whether the incidence of the cardiovascular abnormalities and sudden cardiac death in children found in this material was higher than in other studies.     

Review of pathologic findings in remnant hearts following valve donation

The failure of medical examiners/coroners (ME/C) to allow heart valve donation is a major problem encountered by tissue agencies. Even though many ME/C favor tissue donation they remain responsible for determination of cause and manner of death. In 2001, the Jesse E. Edwards Registry of Cardiovascular Disease was approached by one of the nation's largest tissue procurement agencies (The American Red Cross--ARC) for the purpose of performing cardiovascular pathologic examinations following valve donation. The affiliation existed from October 2001 to January 2005. This study was undertaken to review all 593 postvalve recovery heart remnants received during that time period to tabulate the abnormalities identified and to determine whether donation interfered with the determination of cause of death. For each case, a preliminary cause of death was provided by the ARC. The decedent's body height and weight were also provided. Using the preliminary cause of death, the 593 cases were divided into natural and nonnatural manner of death groups. This division of the cases resulted in 106 cases placed in the natural manner of death group and 487 cases in the nonnatural manner of death group. For each case, all cardiac findings including significant conditions, additional findings, incidental findings, and congenital abnormalities were tabulated. Within the natural manner of death group, 15 cases had a noncardiac cause of death and 91 cases had a cause of death suspected to be cardiac related. In the 91 cases, a total of 132 significant cardiac findings were identified and there were six structurally normal hearts including two infants. In the nonnatural manner of death group, 214 significant cardiac findings were identified and 222 cases had a structurally normal heart. In both natural and nonnatural groups, the most common cardiac abnormality was atherosclerotic coronary artery disease. Other frequently encountered conditions were also identified including 11 cases with acute angle of origin of a coronary artery (five cases natural group; six cases nonnatural group). An important feature of this review was the recognition of potentially inheritable conditions that were diagnosed in both natural and nonnatural manner of death groups. There were three cases of hypertrophic cardiomyopathy (one natural; two nonnatural), three cases of arrhythmogenic right ventricular cardiomyopathy (one natural; two nonnatural), and one case of mitral valve prolapse (natural). In reviewing these cases, we did not feel that valve donation severely impaired cardiac pathologic examination. The benefits of cardiovascular pathologic examination by a cardiac pathologist include the identification of significant and incidental findings and recognition of potentially inheritable conditions.     

Sudden death resulting from lesions of the cardiac conduction system

Sudden unexpected deaths in young persons with noncontributory histories, autopsy results, and drug screen results are a common problem in forensic pathology. As part of the evaluation of such cases, the cardiac conduction system (CCS) should be studied. To determine the type and incidence of lethal CCS lesions, the authors reviewed their files of sudden unexpected cardiac deaths with particular attention to cases with causes of death in the conduction system. Cases of sudden cardiac death in patients aged < or=40 years during a 10-year period (Michigan) and a 4 year-period (Spain) were selected from the files. From this group, cases were identified in which the cause of death was a lethal change in the CCS. The portions of the heart containing the CCS were excised, and at least one hematoxylin and eosin slide and at least one trichrome or elastic trichrome slide per block were studied. In the two centers, 381 cases of sudden cardiac death were identified. The most common causes of sudden cardiac death were arteriosclerotic narrowing of the coronary arteries, cardiomyopathy, and myocarditis. In 82 cases, there was no identifiable cause of death even after complete gross and microscopic autopsy was performed, a medical history was obtained, and a drug screen was performed. In 11 cases, the CCS contained lesions that were considered lethal: narrowing of the atrioventricular node artery by fibromuscular hyperplasia (7 cases) and atrioventricular node tumors (4 cases). The 11 cases accounted for 2.9% of the 381 cases of sudden cardiac death and 11.8% of the indeterminable cases. It was concluded that examination of the CCS in deaths in which the gross and microscopic autopsy, history, and drug screen fail to provide a cause of death can yield a cause of death in a significant percentage of cases. If heart block was not documented during life and no explanatory lesions were found during routine cardiac examination, examination of the CCS can yield valuable information.     

Sudden Death Caused by Anomalous Origin of the Coronary Artery During Exercise

Anomalous origin of the coronary artery (AOCA) is a rare, but important cause of sudden cardiac death among young athletes. Nine autopsy cases (8 male, 1 female; mean age, 17.9 years; age range, 11–31 years) of sudden death during or just after exercise caused by AOCA were reviewed. The exercises performed at the time of death were running (4 cases), soccer (2 cases), and baseball, swimming and kendo (Japanese swordsmanship) (1 case each). In 6 cases, the left coronary artery arose from the right sinus of Valsalva, and in 3, the right coronary artery from the left sinus. The coronary arteries passed between the pulmonary artery and the aorta with an acute angle takeoff from the orifice. Three cases had cardiovascular manifestations prior to death. In cases with cardiovascular manifestations, novel imaging methods should be considered to prevent sudden death.     

Trial investigation of post-mortem non-invasive transnasal endoscopy

We performed a trial investigation of transnasal endoscopy for post-mortem examinations to assess its efficacy in superficial post-mortem examinations. Transnasal endoscopy proved capable of permitting detailed visual inspections of the respiratory and the upper gastrointestinal tract, equal to direct viewing, on an LCD digital display. In 18 (40.9%) of 44 cases, findings obtained by post-mortem transnasal endoscopy (PMTNE) provided valuable clues regarding cause of death. The cases examined included seven deaths by fire, four by hypothermia, four by asphyxia (three involving death by mechanical asphyxia, the other by choking), two by drowning and one case of lung cancer. In two cases, PMTNE also led to informative findings not directly related to the cause of death. Under Japan's current systems, we are required to diagnose the cause of death for over 80% of all the unnatural death cases based solely on superficial post-mortem examinations, in the absence of an autopsy. Introducing PMTNE to superficial post-mortem examinations will undoubtedly provide much more information on the cause of death than relying solely on superficial post-mortem examinations.     

Suicides may be overreported and accidents underreported among fatalities due to dextropropoxyphene

Among prescribed drugs in Sweden dextropropoxyphene (DXP) is the medical compound most frequently responsible for self-inflicted fatal poisonings. To analyze the process leading to the classification of the manner of death in cases of fatalities where DXP caused or contributed to death, a set of explicit and implicit operational criteria was applied retrospectively to fatal DXP poisonings among autopsy cases performed at one department of forensic medicine in Sweden during the six-year period from 1992 to 1997. DXP fatality was found in 113 (2.6%) of the total 4306 autopsy cases. Suicide was recorded in 84 (74%) of these cases, and an undetermined manner of death in 24 (21%). Explicit unambiguous expressions of the intent of the decedent were found in 29 (26%) of the 109 analyzed cases. (In four cases no analysis could be performed). In 46 cases only implicit and no explicit criteria were found. The total number of implicit criteria in individual cases without explicit criteria never exceeded three and in 34 cases no criteria of any type were documented. It is concluded that the classification of the manner of death at DXP fatalities was often based on very limited grounds when the operational criteria were used as a standard for comparison. Information from relatives, friends and others concerning the decedent was rarely accessible. The shortage of information probably led to deficiencies in the death statistics concerning DXP fatalities. Considerable underreporting of accidents and probable overreporting of suicides were found. Failure to report DXP deaths as accidents may delay discovery of the high toxicity of this drug. This might be one of the reasons why the DXP fatality rate is still constantly high in Sweden, while both Denmark and Norway have managed to decrease their DXP death rates by vast restrictions, based on alarming reports of accidental DXP fatalities. In order to guarantee valid death statistics concerning self-inflicted poisoning, the information base leading to classification of the manner of death has to be enlarged. This requires implementation of new routines, including interviews of relatives, acquaintances and significant others to get the information needed to assess the decedent's intention to die. Operational criteria may facilitate the difficult classification process by providing a structured standard, and the set of explicit and implicit criteria applied in this study is recommended.