Complex Suicide by Self‐stabbing and Drowning: A Case Report and a Review of Literature

Sharp force injuries and drowning are methods exceptionally combined in complex suicides. We report a challenging case of complex suicide by self‐stabbing and drowning that illustrates the difficulty in discriminating between homicide and suicide in such circumstances of death. The corpse of a young man was found submerged in a river, stabbed nine times with two wounds that had penetrated the thorax and had caused lung injuries and a hemopneumothorax. The postmortem and histological examinations were consistent with a death caused by drowning, but the manner of death still remained undetermined. Police investigation finally concluded to a suicide, although no suicide note had been left and the victim had no underlying diagnosed mental disorder. The parameters that may help distinguish suicide from homicide at the autopsy should be interpreted in light of a thorough forensic investigation to determine the exact manner of death in such a case.     

Kicking to death - forensic and criminological aspects.

A total of 36,274 forensic autopsies was performed in Berlin, between 1980 and 1987, including 152 cases (0.42%) in which death had been caused by blunt violence due to kicking. Data were collected on both victims and offenders, postmortem findings, causes of death and the way violence had been perpetrated. The greater part of victims and offenders had been males originating from lower social strata. Most of the victims and offenders had been in relationship with each other prior to the offence. Typical course of events: Victims and offenders, under influence of alcohol, became involved in a brawl, usually for trivial reasons, which soon led to physical fighting. When the victim had been knocked to the ground, the offender started forceful kicking. Bleeding to death and head injury were frequent causes of death. More than 50% of all offences were committed by single offenders. The diagnosis of kicking to death can at best be derived from presence of boot traces leaving shaped injuries. The trace-generating boot can be identified as offending tool by means of comparative police investigation. In addition to evaluation of shoe sole profiles, there is other trace-relevant material that may be sampled from a suspected offender's footwear (skin cells, hair, blood, body tissue) and used to identify findings by DNA analysis. There may be injuries with visible patterns supporting suspicion of kicking and trampling, although conclusive confirmation can be obtained only by testimony by a witness or confession by the offender.     

Unusual facial markings and lethal mechanisms in a series of gasoline inhalation deaths

A review of deaths associated with hydrocarbon toxicity from gasoline sniffing in South Australia throughout a 10 year period from July 1987 to June 2002 revealed 4 cases. The victims were all Aboriginal people from remote inland communities. Each death had occurred while the victim was lying in bed sniffing gasoline from a can held to the face. Once unconsciousness had occurred, the mouth and nose had been pressed firmly against the can by the weight of the head. In each case, the effects of gasoline toxicity had been exacerbated by hypoxia and hypercapnia from rebreathing into the container once a tight seal had been established between the face and the can. The circular impressions left by the can edges on the faces of each of the victims provided an autopsy marker that assisted in clarifying the details of the fatal episodes. Discouraging solitary gasoline sniffing in bed may reduce the death rate in communities where this behavior is practiced.     

Uncertainty of determining mode of death in medicolegal material without autopsy — A systematic autopsy study

Systematic autopsy was performed in 807 medicolegal deaths where the police had not requested autopsy. In all cases both the cause of death and the mode of death had been reported at the medicolegal external examination. The autopsy revealed differences in the mode of death in about 4% of all cases. This was due in particular to the problems associated with distinguishing presumed natural deaths from accidents and suicide. The cases of “concealed” suicide were found in particular among the higher age groups. However, no characteristic relationship was found between the proportion of differing modes of death and the age groups. All cases of homicide were recognized at the medicolegal external examination.Malignant disease that had not been diagnosed previously was found in about 4% of the cases, the reason being the large proportion of elderly subjects in the material. Syphilitic aortitis that had not been previously diagnosed was demonstrated in about 1% of all cases, and pulmonary tuberculosis that had not been previously diagnosed was demonstrated in 0.7% of the cases.The conclusion is that the results provide no support for replacing the medicolegal autopsy by medicolegal external examination alone, but rather suggest that the proportion of medicolegal autopsies should be increased.     

Sudden cardiac death following psychoemotional stress

Sudden death from cardiac arrest is described, which occurred after a minor accident. Morphologically, a coronary change was found in the sense of "juvenile coronary atherosclerosis" in connection with intramural bleeding postmortem. As there were no injuries in connection with the accident but psychoemotional stress had occurred, it is concluded that affective resonance resulting from the accident initiated the death. The pathological and pathophysiological relationships are discussed.     

Investigation of cardiac troponins in postmortem subjects: comparing antemortem and postmortem levels

The limitations of autopsy in the diagnosis of death due to ischemic heart disease are well known. In the living, a simple reliable biochemical assay for cardiac troponins is used in the diagnosis of acute myocardial ischemia. Several studies have investigated the use of biochemical assays for cardiac troponins in postmortem subjects as a means to distinguish between a cardiac and anoncardiac cause of death. All of these studies, however, rely upon assigning subjects to "cardiac" or "noncardiac" death on the basis of a postmortem examination. As postmortem examination does not always accurately distinguish between these two groups, this approach is intrinsically flawed.Our study compares antemortem and postmortem cardiac troponin levels in five subjects. The antemortem samples were retrieved from the hospital biochemistry laboratory after each subject's death. The postmortem samples for each subject were taken from different sites and at different times during the early postmortem period.Erratic results bearing little or no relation to the antemortem cardiac troponin level were obtained for all subjects. Four of the five subjects had raised antemortem troponin levels, although only one had a cardiac cause of death.From this, we conclude that postmortem blood is not a suitable substrate for standard biochemical assays of cardiac troponins, which are designed for use on serum taken from living patients. In addition, the results of our study support the view that elevated cardiac troponins are a marker of serious morbidity and are not specific for cardiac injury as the primary cause of morbidity or mortality.     

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.     

Accuracy of cause of death determination without forensic autopsy examination

Medical examiners and coroners commonly determine cause and manner of death without an autopsy examination. Some death certificates generated in this way may not state the correct cause and manner of death. From the case files of the Department of Forensic Medicine in Sydney, Australia, the authors retrospectively reviewed investigative information of all cases in a 6-month period that were initially considered natural deaths (429). The authors, blinded to autopsy results, accepted 261 cases as appropriate for certification without autopsy and assigned a cause of death to each. Per standard local practice, all cases had been autopsied. The actual causes of death as determined by autopsy were then revealed and compared with the presumed causes of death. Most presumed and actual causes of death were cardiovascular (94% and 80%, respectively). The majority of presumed causes of death were listed as ASCVD as the cases lacked features of a more specific cardiovascular process. A large majority of cases had a presumed cause of death of ischemic heart disease based on individual case details. The actual causes of death demonstrated a large breadth of cardiovascular and noncardiovascular disease processes, even though ischemic heart disease accounted for 62% of deaths. The presumed cause of death was completely wrong in 28% of cases. A nonnatural manner of death was present in 3% of cases. This study demonstrates that experienced forensic pathologists may generate erroneous death certificates for cases that are not autopsied.     

Limbs found in water: investigation using anthropological analysis and the diatom test

We report the investigation, using a multi-disciplinary approach, of five cases of dismembered limbs which were recovered from Lake Ontario, Lake Erie and the Niagara River, and examined at the Office of the Chief Coroner for Ontario. In all cases, postmortem examination revealed that the limbs had been disarticulated in the postmortem period, by non-human taphonomic processes. In addition to routine gross examination, the femur and/or tibia were assessed using anthropological methods to give estimates of the sex, age, race and stature of the individual. The anthropologic data facilitated the identification of one of the cases. In all cases, nitric acid extracts of the femoral bone marrow were prepared and examined for the presence of diatoms. In all instances, diatom frustules were recovered from marrow extracts, indicating that drowning was the cause of death or at least a significant contributing factor in the cause of death. The use of the diatom test was helpful in excluding the possibility that the limbs were dismembered from individuals who had died by means other than drowning, and had been subsequently 'dumped' into water. The application of anthropological methods and the diatom test for drowning may significantly enhance the medico-legal investigation of body parts recovered from water, and we present an overview of useful techniques here. Anthropological data may facilitate identification, and the diatom test may establish a cause of death.     

Oronasal blood in sudden infant death.

Oronasal secretions are observed frequently in sudden infant death syndrome (SIDS), but overt blood is uncommonly reported. The literature on oronasal blood in sudden infant death is limited. The goal of this study was to determine the frequency of oronasal blood in sudden infant deaths and to examine possible causative factors. Oronasal blood was described in 28 (7%) of 406 cases of sudden infant death. Oronasal blood could not be attributed to cardiopulmonary resuscitation in 14 cases, including 10 (3%) of 300 cases of SIDS, 2 (14%) of 14 accidental suffocation cases, and 2 (15%) of 13 undetermined cases. Eight of the 10 infants in cases of sudden infant death were bedsharing: 5 with both parents, 2 between both parents. The infant in 1 SIDS case was from a family that had had three referrals to Child Protective Services. Oronasal blood not attributable to cardiopulmonary resuscitation occurs rarely in SIDS when the infant is sleeping supine in a safe environment. Bedsharing may place infants at risk of suffocation from overlaying. Oronasal blood observed before cardiopulmonary resuscitation is given is probably of oronasal skin or mucous membrane origin and may be a sign of accidental or inflicted suffocation. Sanguineous secretions that are mucoid or frothy are likely of remote origin, such as lung alveoli. The use of an otoscope to establish the origin of oronasal blood in cases of sudden infant death is recommended.     

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.     

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.     

Discrepancy between estimated and actual time elapsed after death of a severed head.

A severed head which had been wrapped in seven plastic bags and set in concrete in an airtight insulated plastic box was found approximately 22 months after the occurrence of death. Ammonium magnesium phosphate had formed and on the basis of this and other observed postmortem changes, time elapsed after death was estimated to be from 2 weeks to 6 months. The absence of oxygen is thought to have contributed significantly to the great discrepancy between estimated and actual time elapsed after death.     

Marfan syndrome. A contribution to forensic medicine cases

A 19-year-old school boy suffered from fluctuating uncharacteristic chest pain in the last 20 h before his death. He died unexpectedly within a few minutes of a hemopericardium, which resulted from an aneurysmal rupture of the ascending aorta. The patient's past history as well as the autopsy and ultrastructural findings led to the diagnosis of Marfan's syndrome with alterations of the cardiovascular skeletal system but no ophthalmological involvement ("oligosymptomatic" form of Marfan's syndrome). Appraisal of the cause of death is made more difficult by the fact that medical treatment was undertaken on the same day, whereby subtotal liver crushing was established that had resulted from attempts at resuscitation.     

Death during immersion in water in childhood.

Drowning is a relatively common cause of accidental death in children. Autopsy records at the Adelaide Children's Hospital over a 27-year period from 1964 to 1990 were examined, and 58 cases were found where the cause of death was listed as drowning. In six cases, however, careful examination of the history and postmortem findings provided important additional information that suggested a more complex antemortem sequence of events. Specifically, four patients aged between 6 years, 10 months and 11 years were known to have had epilepsy. A further patient, an 8-year-old boy, died from a subarachnoid hemorrhage due to a bleeding cerebral arteriovenous malformation while swimming. The final patient, an 11-year-old boy who collapsed in a public swimming pool, was found at autopsy to have marked hypoplasia of the right coronary artery. In this series, six of 58 (10.3%) of the pediatric cases had additional underlying medical problems that could either have initiated the drowning episode or caused death due to alternate mechanisms. We present the clinicopathological findings in detail to demonstrate that a high index of suspicion must be maintained in all cases of pediatric drowning, not only for unnatural causes of death but also for additional natural disease processes that may have contributed significantly to the fatal episode. These findings may have particular relevance in jurisdictions where full postmortem examination is not always required by law.     

Fatalities in west Austrian prisons

The purpose of this study is to review 23 causes of death that have occurred in Western-Austrian prisons from 1974 to 1989. The majority of them (11 cases) were due to suicides. Among 9 cases of natural death there was a 25 years old man, who died of an unknown purulent meningoencephalitis. Two drunken prisoners had not been supervised and therefore died of alcohol poisoning. In one case the police jail physician did not recognize an epidural hematoma.     

Diagnostic problems associated with cadaveric trauma from animal activity

Analysis of a series of deaths between 1986 and 2001 resulting from natural disease, accidents, suicides, and homicide, where postmortem animal activity had traumatized bodies, was undertaken at the Forensic Science Center in Adelaide to demonstrate the range of lesions that may occur and problems in interpretation that result. Tissue damage had been caused by a variety of animals, including fly larvae, ants, birds, dogs, rodents, sea lice, and sharks. Postmortem animal activity had disguised injuries, modified wounds, and created the appearances of inflicted injury. Problems with identification occurred after postmortem facial trauma, and loss of organ parenchyma had interfered with, or precluded, the precise determination of the manner of death in some cases. Specific kinds of tissue and organ damage may occur after death, necessitating careful assessment of lesions in a search for characteristic features of animal activity. The pattern of lesions may enable identification of the particular species of animal involved.     

Applications of Social Network Media in Medicolegal Death Investigation

With the increased popularity of online social networking services (SNS) such as Facebook, LinkedIn, Twitter, and Google+, we propose that a wealth of new resources is available for medicolegal death investigation. Recognizing this potential, we identified cases in which social media had been useful in the past in our office and asked our investigative staff to consider using social media in current cases. These cases provided illustrative examples for this primer regarding how information from SNS was used in death investigations in our office. Information gleaned from online social media aided in establishing preliminary identification of a decedent, locating next‐of‐kin, investigating the circumstances of death as relevant to the manner of death, corroborating eyewitness accounts, and providing information relevant to time of death. Potential pitfalls were identified, such as shared accounts or online impostors. SNS proved useful to the medicolegal death investigator and medical examiner, so long as their limitations were recognized.     

An unusual accidental death from positional asphyxia

Death from postural or positional asphyxia takes place in circumstances when the victim's body assumes an abnormal position compromising the process of respiration. The diagnosis is usually based on circumstantial evidence in conjunction with excluding other significant underlying causes of death. This case report is about a 37-year-old man who had been drinking the previous night and was found dead in the morning in a knee-chest position. The forensic medical examiner had the opportunity to examine and photograph the scene of death while the body was still in its original position. Apart from a blood alcohol level of 290 mg/100 mL, marked congestion of the face, and petechial hemorrhages on the conjunctivae, autopsy findings were unremarkable. There were no injuries or pathological findings to account for his death. Death was certified as due to postural asphyxia secondary to intoxication by alcohol.