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.     

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.     

The impact of psychological autopsies on medical examiners' determination of manner of death

This study evaluated the impact of psychological information on medical examiners' determination of manner of death in equivocal cases. Ten cases, a typical and equivocal case for each of five case types (single car, child, autoerotic, psychotic, and Russian roulette death) were evaluated for manner of death by 195 medical examiner subjects. From this sample 95 control subjects received 10 cases made up of physical and circumstantial evidence, while 100 experimental subjects received the same 10 cases expanded with brief psychological autopsies. Psychological information was shown to have a statistically significant impact on subjects' determination (and certainty) of manner of death is equivocal cases and even in some typical cases.     

Suicide classification--clues and their use. a study of 122 cases of suicide and undetermined manner of death

In order to identify clues to forensic pathologist's classification of suicide, the forensic files of 100 consecutive cases of suicide, and 22 cases of undetermined manner of death, were analysed. Some specific causes of death, suicidal communication and other circumstantial evidence suggesting suicidal intent explained all but three classifications. Problematic cases concerned death by poisoning and by submersion, alcohol-dependent persons and subjects with positive blood alcohol concentration at autopsy. Guidelines to support the police investigation as well as the medico-legal examination can probably reduce the number of undetermined cases in cases of possible suicide.     

Percentage of body recovered and its effect on identification rates and cause and manner of death determination

Anthropologists frequently encounter cases in which only partial human remains are recovered. This study reports how the percentage of the body recovered affects identification (ID) rates and cause and manner of death determination. A total of 773 cases involving anthropology consults were drawn from the New Mexico medical examiner's office (1974-2006). Results indicate a significant correlation between body percent recovered and ID rates, which ranged from 89% for complete bodies to 56% when less than half the body was present. Similar patterns were evident in cause/manner determination, which were the highest (83% and 79%, respectively) in complete bodies but declined to 40% when less than half the body was found. The absence of a skull also negatively impacted ID and ruling rates. Findings are compared with general autopsy ID rates (94-96%) and cause/manner determination rates (96-99%) as well as prior published rates for individual casework and mass death events.     

Open revolver cylinder at the suicide death scene

Revolvers with an open cylinder were found at three death scenes of apparently self-inflicted gunshot wounds. All three handguns were Smith & Wesson.38 or.357 revolvers. Investigation revealed that firing the gun with the thumb on the cylinder release latch could disengage the cylinder. A combination of gravity and recoil impact against the thumb would open the cylinder and even allow the casing and the unspent cartridges to fall from the gun, creating a confusing death scene.     

New criteria for diagnostics of sudden cardiac death in forensic medicine

New data on characteristics of sudden cardiac death are provided. It is characterized by hypohydration of the brain, elevated cerebral impedance, a sharp fall of the index of coronary heart arteries passability, mostly areactive affection of the stem nuclei of the brain.     

Strontium90 for determination of time since death

Strontium90 (Sr90) is an artificial nuclear fission product of the atmospheric a-bomb testing between 1945 and 1979. It was spread throughout the atmosphere in the following years. Sr90 is an analogue to calcium and therefore enriched in human bones. Several studies especially in the 1960s and 1970s were undertaken to investigate the Sr90 burden and the resulting incorporated radiation in humans, but present studies are missing. In this study nine bone samples, three from 1931/32 and six from 1989 to 1994 were examined by measuring the Sr90 radiation. The samples from 1931/32 did not show any Sr90 activity. All the samples from 1989 and later showed a Sr90 activity, but the intensity was very variable. Subsequent investigations should be done to determine the cut-off year for measurable Sr90 activity. Furthermore the determination of a specific time since death depending on Sr90 activity should be possible, due to the ranging Sr90 pollution between 1950 and 1980 and different uptake in adolescents and adults.     

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.     

Cause and manner of death among users of anabolic androgenic steroids

Medicolegally investigated deaths among 34 male users of anabolic androgenic steroids (AAS) are described. Nine persons were victims of homicide, 11 had committed suicide, 12 deaths were judged as accidental and 2 as indeterminate. In two cases of accidental poisoning, the levels of pharmaceuticals and illicit drugs were considered too low to be the sole cause of death and AAS was considered part of the lethal polypharmacia. Chronic cardiac changes were observed in 12 cases. In two cases of accidental poisonous deaths, these changes were regarded as contributory cause of death. Homicides, suicides, and poisonings determined accidental or indeterminate in manner were related to impulsive, disinhibited behavior characterized by violent rages, mood swings, and/or uncontrolled drug intake. The observations in the present study indicate an increased risk of violent death from impulsive, aggressive behavior, or depressive symptoms associated with use of AAS. There are also data to support earlier reports of possible lethal cardiovascular complications from use of AAS. Furthermore, a contributing role of AAS in lethal polypharmacia is suggested. Finally, the observations indicate that use of AAS may be the gateway of approach to abuse of other psychotropic drugs.     

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.