Suicide in Fulton County, Georgia (1975-1984)

Demographic and trend analysis of 881 consecutive suicides in blacks and whites is presented. For the years 1975 through 1984, the suicide rate was 15.1/100 000 and did not significantly change. White males were overrepresented in all age groups, had an overall suicide rate of 34.9, and showed a small but statistically significant increase in rate which was not accounted for by any specific age group. White females, in general, were represented in proportion to their prevalence in the population, and those ages 20 to 24 demonstrated an increasing suicide rate which was small. Black males were at highest risk in their twenties, showed no significant trends, and were also represented near their prevalence in the population. Black females of all ages were underrepresented, and had low suicide rates which decreased with time. No significant rate changes were noted for teenagers or the elderly. Firearms was the method of choice in all groups, although methods varied with age, race, and sex, and male children preferred hanging. Small but significant increases were noted for the prevalence of nondrug methods in females and carbon monoxide deaths in white males. Similarities and differences to larger scale studies are discussed. Suicide may have characteristics unique to given geographical areas and pervasive to all areas. The authors advocate study and publication of local data to clarify further the nature of suicide.     

Suicide by jumping from high-rise hotels. Fulton County, Georgia, 1967-1986

During a 20-year period from 1967 through 1986, 19 suicidal jumps from high-rise hotels (HRHs) accounted for 24% of all fatal jumping episodes and 1% of all suicides in Fulton County, Georgia, U.S.A. The rate of suicidal jumps from HRHs did not increase during the study period. The number of fatal jumps per hotel-year correlated with the height of the interior hotel atrium. The mean age for all victims was 34 years, and 63% of victims were white males. The majority of victims were local residents who were alone when they jumped and were not registered hotel guests. Registered guests tended to jump from the floor on which their room was located whereas nonregistered individuals tended to jump from the upper-most floors in the hotel. Of 19 HRH jumps, 13 occurred from the inside. Suicide notes were found in 37% of cases. HRH jumps were least common between 6 p.m. and midnight, all decedents were dressed in street clothing, only one was heard to have screamed, and all but one were dead on the scene. Alcohol and drug involvement was minimal. We hope that this information will be useful to those who investigate such deaths and to those who study the behavioral manifestations of suicide.     

Evaluation of certifier practices regarding alcohol-related deaths: Fulton County Medical Examiner's Center, Atlanta, Georgia, 2004

CONTEXT: Alcohol can contribute to various manners of death by acute intoxication that places a person at risk for fatal injury, acute fatal alcohol poisoning, or the various fatal complications of chronic abuse with or without superimposed acute intoxication. The reporting of alcohol use on the death certificate may vary with office policy or procedure, certifier judgment, and the timing of information received during investigation. OBJECTIVE: To determine the number of deaths including mention of alcohol use in the investigative case file, the number of death certificates on which alcohol use is reported, the number of discrepancies between the 2, and the possible reasons for observed discrepancies. DESIGN, SETTING, AND PARTICIPANTS: Retrospective case review of all deaths where alcohol use was mentioned in the investigative case file and/or on the death certificate for deaths investigated by the Fulton County Medical Examiner in Atlanta, Georgia, during a 1-year period between January 1, 2004, and December 31, 2004. MAIN OUTCOME MEASURES: Percentage of deaths with alcohol use reported on the death certificate, tabulation of where and how alcohol use is reported on the death certificate, and tabulation of the differences between the investigative case file and death certificate regarding alcohol's possible role in causing death. RESULTS: Among the 1324 deaths certified by the office, 105 (8%) had alcohol use reported on the death certificate. The majority (67%) of these cases were natural deaths. Sixty-nine (5%) deaths had mention of alcohol use in the investigative case notes but did not include it on the death certificate. Twenty-five (2%) deaths had mention of alcohol on the death certificate but did not have mention of it in the investigative case file based on our search criteria. However, subsequent review of additional case follow-up information disclosed a history of alcohol use or acute intoxication in each case. CONCLUSIONS: The data show that more natural deaths are considered to be directly caused by alcohol than other manners of death. For the unnatural manners of death (excluding acute alcohol poisoning), alcohol use is often viewed by medical examiners as an incidental, associated finding or risk factor surrounding the circumstances of death rather than being an actual cause of death. In such cases, alcohol use is often omitted from the death certificate. For deaths directly caused by alcohol, the proportion of cases involving possible underreporting or overreporting of alcohol involvement was relatively small and usually involved the omission of chronic alcohol use from the death certificate. Researchers need to be aware of potential limitations of death certificate data for studying alcohol-related deaths.     

Identification of the unidentified deceased: turnaround times, methods, and demographics in Fulton County, Georgia

CONTEXT: Multiple methods may be employed in an attempt to identify deceased individuals who are unidentified when reported to the medical examiner or coroner. The success and turnaround times of various methods differ. OBJECTIVE: To determine the number of deaths initially involving unidentified individuals, their demographics, the methods used and turnaround times for cases in which identification was successful and the portion of cases that remain unidentified for significant periods of time. DESIGN, SETTING, AND PARTICIPANTS: Retrospective case review of all decedents who were initially unidentified when death was reported to the Fulton County Medical Examiner in Atlanta, Georgia, during a 1-year period between May 2003 and May 2004. MAIN OUTCOME MEASURES: Rate per 1000 deaths which involved an unidentified decedent, tabulation of methods used to make identifications, and rate of cases remaining unidentified. RESULTS: Of 2279 deaths reported to the office, 100 were originally unidentified, resulting in a rate of 44 unidentified decedents per 1000 deaths reported. Those who remained unidentified involved 6 cases, resulting in a "cold case" rate of 2.6 per 1000 deaths. Seventy-eight percent were identified within 2 days, and the most common successful methods were visual identification (52%) and fingerprints (31%). Dental (10%), x-ray (4%), and other methods (6%) were least commonly used. Of the 94 persons identified, all identifications occurred within 29 days. DNA procedures were not needed in most cases, and in the few cases where such tests were needed, results were either unavailable or failed to show a match with known samples. CONCLUSIONS: The majority of unidentified deceased individuals were identified within 2 days, with visual verification or fingerprints accounting for about 83% of methods successfully employed. The medical examiner noted a rate of 44 unidentified deceased persons per 1000 death reports, with an ultimate "cold case" (long-term unidentified) rate of about 2.6 cases per 1000 death reports. These data may be useful in developing office policy and procedure regarding the procedural and temporal aspects of investigations centered on achieving identification and making dispositions of unidentified deceased bodies.     

Identification of the unidentified deceased and locating next of kin: experience with a UID web site page, Fulton County, Georgia

BACKGROUND: Medical examiner and coroner offices may face difficulties in trying to achieve identification of deceased persons who are unidentified or in locating next of kin for deceased persons who have been identified. The Fulton County medical examiner (FCME) has an office web site which includes information about unidentified decedents and cases for which next of kin are being sought. METHODS: Information about unidentified deceased and cases in need of next of kin has been posted on the FCME web site for 3 years and 1 year, respectively. FCME investigators and staff medical examiners were surveyed about the web site's usefulness for making identifications and locating next of kin. RESULTS: No cases were recalled in which the web site led to making an identification. Two cases were reported in which next of kin were located, and another case involved a missing person being ruled out as one of the decedents. The web site page is visited by agencies interested in missing and unidentified persons, and employees do find it useful for follow-up because information about all unidentified decedents is located and easily accessible, electronically, in a single location. CONCLUSIONS: Despite low yield in making identifications and locating next of kin, the UID web site is useful in some respects, and there is no compelling reason to discontinue its existence. It is proposed that UID pages on office web sites be divided into "hot" (less than 30 days, for example) and "warm" (31 days to 1 year, for example) cases and that cases older than a year be designated as "cold cases." It is conceivable that all unidentified deceased cases nationally could be placed on a single web site designed for such purposes, to remain in public access until identity is established and confirmed.     

Identifying the dead: methods utilized by the Pima County (Arizona) office of the medical examiner for undocumented border crossers: 2001-2006

The Pima County (Arizona) Office of the Medical Examiner has seen a dramatic rise over the past 6 years in the number of deaths related to the illegal crossing of our international border with Mexico. This rise in deaths is undoubtedly related to an increase in the number of foreign nationals who cross into the various Arizona jurisdictions that utilize the Pima County Medical Examiner to investigate their unnatural deaths. Because of the utterly dangerous nature of trekking across the Sonoran Desert, especially in the summer months, many of these unfortunate migrants succumb to the effects of heat-related illness and perish along the journey. The combined effects of a dry, hot environment and the remoteness of some of the trekking corridors can quickly render a deceased person unidentifiable by visual means. Thus, our office is faced with not only an increase in the number of deaths requiring medico-legal investigation but also an increase in the number of decedents needing additional specialized examinations in an effort to effect identification. This paper attempts to outline the problems and the methods utilized by our office over the past 6 years in the identification process of undocumented border crossers. It is hoped that this paper, as well as the others presented at this symposium, will allow for the sharing of information amongst all medical investigators who assist in the identification of these migrants. The identification of these individuals takes on added importance when one considers the possible nationalities, and perhaps motivation for entering into the US, of those that remain unidentified.     

Deaths in custody. Atlanta City Jail and Fulton County Jail, 1974-1985

A total of 53 in-custody deaths that occurred in Atlanta-Fulton County, Georgia, between 1974 and 1985 are reviewed. Custody deaths showed characteristics similar to those described in other geographical areas. The majority of deaths were due to natural causes, about one-fourth were suicides, and homicides were rare. For jails that housed a daily population of about 1,000 prisoners, an average of 4.4 deaths were observed annually. Men predominated, and racial makeup paralleled the general prison population. Seizures, alcohol-related illness, and cardiovascular disease caused over half of the natural deaths. All suicides were accomplished by hanging. Over two-thirds of the incidents that led to death occurred in the prisoner's cell, and about one-half of the victims were found dead in their cells. Two-thirds of those who died in custody had been arrested for crimes in which persons were not harmed, while nearly two-thirds of those committing suicide had been arrested for crimes against persons. Deaths in custody are expected events, and familiarity with the circumstances under which they occur should be helpful in enabling prison managers to establish policies and procedures to minimize their occurrence.     

Recovery of decomposed and skeletal human remains in the "Green River Murder" Investigation. Implications for medical examiner/coroner and police

The Green River Murder Investigation in King County, Washington, is currently the longest active serial murder investigation in U.S. history. During its course, over 26 separate scenes with from one to five victims each have been processed. The experience of the authors is presented in order to acquaint other agencies with techniques of outdoor scene processing that have evolved during recovery of remains from Green River and other skeletal cases.     

A 10-year epidemiologic review of homicide cases in children younger than 5 years in Fulton County, GA: 1996-2005

The primary purpose of this study was to present the epidemiologic review of homicide deaths certified by the Fulton County Medical Examiner's Office from January 1, 1996 through December 31, 2005 in children younger than 5 years. The secondary purpose of this study was to determine if the observed cases of homicide deaths among children younger than 5 years in Fulton County are significantly greater than expected when compared with those in the State of Georgia. For purposes of this study, only homicide deaths of Fulton County residents were included. The authors reviewed all homicide cases in children younger than 5 years: infancy (<1 year) and early childhood (1-4 years). χ values were calculated using Epi Info (version 3.4.1; Centers for Disease Control and Prevention, Atlanta, Ga) to determine differences in homicide among age group, race, and sex variables. In addition, a χ test at the α level of 0.05 was done to determine if the observed cases of homicide deaths among children younger than 5 years in Fulton County were significantly greater than expected when compared with those in the State of Georgia. There were 49 homicide cases in children younger than 5 years identified over this 10-year period. The yearly distribution of these 49 homicide deaths ranged from 1 death in 2003 to 9 deaths in 2004. Most of the patients were male (n=29, 59.2%) and black (n=44, 89.8%). Between infancy and early childhood cases, homicide victims were nearly equally divided between the 2 groups. However, χ values showed that decedents younger than 5 years are more likely to have died of homicide compared with decedents 5 years or older (odds ratio [OR], 1.74; 95% confidence interval [CI], 1.29-2.35). Black decedents younger than 5 years are more likely to have died of homicide compared with other races (OR, 3.21; 95% CI, 1.21-9.28). Male and female decedents are equally at risk to have died of homicide (OR, 1.14; 95% CI, 0.61-2.11). The authors also determined that the total homicide risk for children younger than 5 years in Fulton County during the years 1996 to 2005, at the α level of 0.05, is 1.8 relative to the state. Brain injury was the primary cause of death in most cases (n=23, 46.9%). Although this study was unable to collect information on the victim's suspect/offender characteristics, it was noted that only 37% of the cases (n=18) went to trial. Most homicide investigations were under the Atlanta police jurisdiction (n=28, 57.1%). Results from this study may assist local and state government officials in recognizing the epidemiologic characteristics of children at risk to help them allocate limited resources efficiently and implement preventive measures to at-risk populations effectively.     

Pseudo-subarachnoid hemorrhage of the head diagnosed by computerized axial tomography: a postmortem study of ten medical examiner cases

In this report, we describe ten cases of pseudo-subarachnoid hemorrhage on computer axial tomography (CT) scan of the head. A pseudo-subarachnoid hemorrhage is a false positive finding by CT of the head in which the scan is interpreted as being positive for a subarachnoid hemorrhage not substantiated by subsequent neuropathologic findings. This study is a retrospective review of postmortem cases brought into the Office of the Chief Medical Examiner for the State of Maryland over a three-year period (from 1997 to 2000). We compared the clinician's impression of the CT scan with the postmortem neuropathology. The clinical diagnosis of subarachnoid hemorrhage was based on misinterpretation of non-contrast CT scans of the head. In six of the ten cases, the reading was performed by a radiologist and in four cases by nonradiologist physicians (emergency room physician, neurologist, or neurosurgeon). All the patients survived between a few hours to a few days after being admitted to the hospital. For most of the cases (80%), the neuropathology showed hypoxic/ischemic encephalopathy. The most common cause of death (four out of ten cases) was narcotic intoxication. This report is submitted so that clinicians and pathologist become more familiar with this entity.     

Recent status of the medical examiner system in Japan: demographic variation of medicolegal deaths in Hyogo Prefecture and uncertainty in medicolegal investigations conducted by medical practitioners.

The medical examiner system has been steadily abolished in Japan. Instead, medicolegal investigations are entrusted by the police to medical practitioners, who are not permitted to perform autopsies. The necessity for the medical examiner system was assessed through inquest records in Hyogo, one of the three prefectures which still have medical examiner systems. Standardized mortality ratios (SMRs) for accidents and suicides were negatively associated with population density, being high in rural areas with a large proportion of elderly citizens, while the SMR for natural deaths was high in urbanized areas and associated with the proportion of inquests to total resident deaths. The high proportion of inquests, however, did not always mean that inquest records were of good quality. Significant differences in the quality of medicolegal investigations seemed to exist between medical examiners and medical practitioners. That is, in order to certify the cause-of-death, medical examiners performed autopsies in about half of their cases, while only 2% of medical practitioner cases were subjected to autopsies. Medical practitioners, who certified the cause-of-death as "heart failure" without advising an autopsy, were regularly entrusted with inquests. It is likely that the causes-of-death for medicolegal cases may be questionable since more than 85% of all medicolegal deaths were investigated by medical practitioners, which may cause inaccuracy in at least 3-7% of mortality statistics. It is necessary to educate medical practitioners concerning the importance of mortality statistics and ICD and on the validity of autopsies, in order to obtain accurate mortality statistics from medicolegal cases.     

Natural death as viewed by the medical examiner: a review of 1000 consecutive autopsies of individuals dying of natural disease

A study of 1000 consecutive autopsies of individuals dying of natural disease was conducted. Cardiovascular disease was responsible for 60.9% of all deaths with coronary artery disease--not only the main cause of cardiovascular death but also the main cause of all natural deaths--accounting for 45.1% of such cases. Diseases of the central nervous and respiratory systems accounted for 8.7 and 8.6%, respectively, of the natural deaths. Seizure disorders and pneumonia were the main causes of death in these organ systems. There were 124 deaths of children less than one year in age, 91 of which were due to sudden infant death syndrome (SIDS). All of the SIDS deaths were in children less than 10 months old.     

Differentiating cause-of-death terminology for deaths coded as sudden infant death syndrome, accidental suffocation, and unknown cause: an investigation using US death certificates, 2003-2004

We compared written text on infant death certificates for deaths coded as sudden infant death syndrome (R95), unknown cause (R99), and accidental suffocation (W75). Using US mortality files supplemented with the death certifiers' written text for all infant deaths with International Classification of Diseases (ICD)-10 assigned codes R95, R99, and W75, we formed cause-of-death subcategories from common themes identified from the written text. Among all infant deaths in 2003-2004, the underlying cause of death was listed as R99 for 2128 deaths, R95 for 4408 deaths, and W75 for 931 deaths. Among the postneonatal deaths, the differences in subcategories varied between assigned ICD-10 codes: for R99-coded deaths, 45.8% were categorized as "Unknown" and 48.6% as "Pending"; for R95-coded deaths, 67.7% were categorized as "sudden infant death syndrome (SIDS)"; and for W75-coded deaths, 76.4% were categorized as "Suffocation." Examination of the written text on the death certificates demonstrates variability in the assigned ICD-10 codes which could have an important effect on the estimates of SIDS cases in the United States.     

Results of the 2003-2004 GEP-ISFG collaborative study on mitochondrial DNA: focus on the mtDNA profile of a mixed semen-saliva stain

We report here a review of the seventh mitochondrial DNA (mtDNA) exercise undertaken by the Spanish and Portuguese working group (GEP) of the International Society for Forensic Genetics (ISFG) corresponding to the period 2003-2004. Five reference bloodstains from five donors (M1-M5), a mixed stain of saliva and semen (M6), and a hair sample (M7) were submitted to each participating laboratory for nuclear DNA (nDNA; autosomal STR and Y-STR) and mtDNA analysis. Laboratories were asked to investigate the contributors of samples M6 and M7 among the reference donors (M1-M5). A total of 34 laboratories reported total or partial mtDNA sequence data from both, the reference bloodstains (M1-M5) and the hair sample (M7) concluding a match between mtDNA profiles of M5 and M7. Autosomal STR and Y-STR profiling was the preferred strategy to investigate the contributors of the semen/saliva mixture (M6). Nuclear DNA profiles were consistent with a mixture of saliva from the donor (female) of M4 and semen from donor M5, being the semen (XY) profile the dominant component of the mixture. Strikingly, and in contradiction to the nuclear DNA analysis, mtDNA sequencing results yield a more simple result: only the saliva contribution (M4) was detected, either after preferential lysis or after complete DNA digestion. Some labs provided with several explanations for this finding and carried out additional experiments to explain this apparent contradictory result. The results pointed to the existence of different relative amounts of nuclear and mtDNAs in saliva and semen. We conclude that this circumstance could strongly influence the interpretation of the mtDNA evidence in unbalanced mixtures and in consequence lead to false exclusions. During the GEP-ISFG annual conference a validation study was planned to progress in the interpretation of mtDNA from different mixtures.     

Trends in suicide by carbon monoxide inhalation in King County, Washington: 1996-2009

Carbon monoxide (CO) inhalation is one of the leading methods of suicide in the United States. A sharp increase in suicide by inhaling the CO produced from burning charcoal has been reported in parts of Asia; however, the incidence of this method has not been determined in a U.S. population. Thus, we determined trends of CO suicide in the ethnically diverse population of King County, Washington, U.S.A. During the period 1996-2009, we identified 158 cases of suicide by CO poisoning, with 125 because of automotive exhaust, 26 because of charcoal burning, and seven from other CO sources. While historical U.S. data indicate >99% of CO suicides in the United States occurring by automobile exhaust inhalation, in the most recent years analyzed, c. 40% of CO-related suicides in King County, Washington, were because of charcoal burning, indicating a possible shift in suicide trends that warrants further scrutiny in additional populations.