J Forensic Sci, 2016

doi: 10.1111/1556-4029.13179
PAPER Available online at: onlinelibrary.wiley.com

PATHOLOGY AND BIOLOGY

Elena Tugaleva,1 M.D.; Donald R. Gorassini,2 Ph.D.; and Michael J. Shkrum,1 M.D.

Retrospective Analysis of Hanging Deaths in

Ontario

ABSTRACT: Hanging deaths from investigation standpoint are rarely problematic. Unusual circumstances can on occasion raise suspicion of
foul play. Associated neck injuries are reported in the literature with variable frequency (from 0% to 76.8%). This study retrospectively ana-
lyzed 755 hanging deaths in Ontario (Canada) to evaluate the demographic features and circumstances of hanging fatalities, and the frequency
of hanging-related neck injuries. A number of cases showed unusual/special circumstances (e.g., complex, double suicides, restraints). Among
632 cases with complete autopsies, hyoid and larynx fractures were present in 46 cases (7.3%) with the most common being isolated hyoid
fractures. The incidence of cricoid fractures was 0.5% and cervical spine injuries, 1.1%. A higher incidence of neck injuries occurred among
males, long drop hangings, and in cases with complete suspension. There was a tendency for the number of fractures to increase with increas-
ing age and weight of the deceased.

KEYWORDS: forensic science, forensic pathology, autopsy, hanging, neck injuries, hyoid, larynx

Hanging is one of the most common methods of suicide

Materials and Methods
around the world. This likely stems from the easy accessibility
of victims to a myriad range of ligatures and locations to sus- This study was based on retrospective analysis of consecutive
pend themselves and the relatively rapid lethality of this cases of hanging deaths that happened in the province of Ontario
method of suicide. From a death investigation standpoint, during the two-year period from January 1, 1998, to December
hanging fatalities are rarely problematic. Occasionally, a 31, 1999. This study period was chosen to allow evaluation of a
dilemma arises in identifying the manner of death, most com- sufficient number of cases which had a complete postmortem
monly in trying to distinguish a suicidal hanging from an examination. In current forensic pathology practice in Ontario,
accidental event. Extremely rare are cases of hanging due to hanging death postmortems tend to be limited to external exami-
homicidal violence (1–6). Typically, hanging is associated with nation only if the circumstances indicate definite suicidal intent
a lesser degree of external and internal trauma compared with (e.g., suicide note, recent or past suicidal ideation, or attempts)
the other types of neck compression, specifically ligature and in an individual, usually male, in a secure environment. Post-
manual strangulation (7,8). mortem examinations were performed in different institutions,
The data in the literature regarding frequency of including specialized forensic pathology units, and teaching and
hanging-related neck injuries are controversial. The reported community hospitals.
incidence of occurrence of laryngeal and hyoid fractures varies Data were collected from the files in the archives of the Office
from 0% to 76.8% (9–11). A number of factors are recog- of the Chief Coroner for Ontario. These included the coroner’s
nized which influence the incidence of various hanging-related investigation statements, police reports of incidents with witness
neck injuries. Taking these factors into consideration while statements, and reports of postmortem examination. Relevant
evaluating postmortem findings further assists their accurate epidemiological data of the deceased individual (i.e., sex, age,
interpretation. weight, height, and body habitus) were recorded using standard-
The first goal of this study was to review the population ized datasheets. The latter also included information on the man-
demographics and the incidence of unusual and special circum- ner of death, suicidal risk factors (e.g., past history of mental
stances in hanging fatalities which can raise concerns for investi- illness, suicide threats, prior attempts, note), and resuscitation/
gators. The second objective was to determine the incidences of survival details. Unusual circumstances (e.g., restraints, com-
different hanging-related neck injuries and correlate them with bined suicide) were recorded. As well, collected data included
major recognized contributing factors. information on the type of suspension and ligature, and toxico-
logical findings.
All cases were studied in order to evaluate population demo-
graphics, unusual circumstances of death, and historical data
1
Department of Pathology & Laboratory Medicine, London Health related to risk of suicide. Only cases which had a full post-
Sciences Centre, London, ON, N6A 5A5, Canada.
2
Department of Psychology, King’s College, Western University, London,
mortem examination were evaluated to determine the frequency
ON, N6A 2M3, Canada. and distribution of hanging-related injuries.
Received 8 Sept. 2015; and in revised form 23 Jan. 2016; accepted 30 All postmortem findings were classified as either hanging
Jan. 2016. related or unrelated. The former category included injuries to the

© 2016 American Academy of Forensic Sciences 1

2 JOURNAL OF FORENSIC SCIENCES

neck-throat skeleton (i.e., hyoid bone, laryngeal cartilages, and GENDER

cervical spine) and neck soft tissue injuries away from the site male
200 female
of fracture (including injuries to neck strap musculature, carotid
arteries, tongue). Injuries unrelated to hanging were subdivided
into recent and healing/remote injuries as well as by major
mechanisms of infliction (i.e., blunt impact, sharp force, fire- 150

NUMBER OF CASES
arms).
When stratifying incidents by the type of suspension, the ter-
minology of complete and incomplete suspension was applied.
100
The former included cases where the body was suspended
unsupported. For the latter, some form of body support was pre-
sent, that is, any part(s) of the body was supported by the
ground or other structures (i.e., body against the wall, door). 50

Cases when the toes/feet of the deceased were just touching the
ground (partial contact with the ground) were analyzed sepa-
rately and included in the complete suspension category.
0
The data were entered in standardized datasheets and further 0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 >90
analyzed using IBM SPSS Statistics 20 (Statistical Package for AGE GROUPS
the Social Sciences) for Windows.
FIG. 1––Case distribution by age and gender.

Results
documented. Suicide notes were found in 151 cases (20.5%) and
A total of 761 cases of hanging were registered in Ontario for preceding threats to kill oneself were recorded in 138 cases
the period from January 1, 1998, to December 31, 1999 (374 (18.7%). In 267 cases (36.2%), there was a history of prior sui-
cases in 1998 and 387 cases in 1999). Six cases where post- cide attempts including 97 cases (13.2%) where attempts were
mortem reports were not available were excluded from the study. multiple. In 37 cases (13.9% of cases with a history of attempted
From the remaining 755 cases, 737 (97.6%) were ruled as sui- suicides), prior attempts were by hanging. In addition to these
cides in the course of coroners’ investigations. Nine cases cases, there were 16 cases with evidence of a failed hanging
(1.2%) were accidents, and two cases (0.3%) were homicides. attempt a short time prior to the fatal hanging. In the majority of
For seven cases (0.9%), the manner of death remained undeter- these cases, there was a history of the deceased phoning some-
mined. For five of these cases, the uncertainty was whether one to report an unsuccessful first hanging attempt. In two of
hanging was suicidal or accidental. Among them was a case of the cases, unsuccessful attempts were witnessed. In only three of
possible autoerotic asphyxiation. In two cases, the manner of the sixteen cases, two separate ligature marks were observed.
death was either suicide vs. homicide in one and accident vs.
homicide in the other. Complete autopsies were performed in
Special Circumstances
632 cases (83.7%). Sixty-eight cases (9%) were limited to exter-
nal examination only. In 55 cases (7.3%), no postmortem exami- Near-hanging—Of 44 decedents (5.8%) who exhibited vital
nation was performed. signs at the scene or were resuscitated, 22 died within the first
36 h and 22 survived from 2 to 135 days at hospital. In 30
cases, full autopsies were performed. One case had an external
Population Demographics
examination only. In the majority of longer-term survivors (over
Age and Sex—The mean age of the deceased individuals was 2 days), the cause of death was hypoxic–ischemic encephalopa-
40.6 years (the youngest individual was 2 years of age and the thy due to hanging. The survivors were overall younger (mean
oldest was 94). Case distribution by age and sex is demonstrated age of 35.3 years) and showed higher female representation
in Fig. 1. There was a male predominance: 624 (82.6%) dece- (27%). One of the near-hanging victims sustained a hyoid frac-
dents were males and 131 (17.4%) were females. Similar distri- ture, and another had cervical spine dislocation.
butions were observed in cases which had complete autopsies,
with the mean age being 39.8 years (males—39.8; females— Pediatric Deaths—Fifty-six deceased (7.4%) were children
39.5) and a male predominance of 81.3%. aging from 2 to 17 years with 34 (4.5%) being 15 or younger.
The youngest were 2- and 4-year-old girls. These children were
Past Psychiatric History and Suicidal Intent—Of 613 suicidal hanged by their mothers who then hanged themselves. Of the
hangings where prior psychiatric history was described in the remaining 54 cases, 46 were suicides, six accidents, and two
affirmative or not, 579 individuals (78.6%) had a history of undetermined.
some type of mental illness. This included mood disorders, per- All accidental deaths were unwitnessed by adults and involved
sonality/behavior disorders, and other psychiatric conditions, children from 4 to 15 years of age. There were an equal number
including substance-related and addictive disorders. History of of boys and girls. These included three cases of younger children
depression was documented in 442 cases (60%). A history of accidentally suspended while playing (by the child’s own cloth-
substance abuse was reported in 200 (27.1%) cases. In 54 cases, ing, a window blind cord, and a dance rope), two cases of acci-
substance abuse was present without any other diagnosed psy- dental entanglement with a ligature while doing some purposeful
chiatric disorder. In only 22 cases (3%) was there a definitive activity, and one case where hanging was apparently a threaten-
statement of no past psychiatric history. ing activity after the child was disciplined for misbehavior.
In approximately half (49.5%) of suicidal hangings, the pres- The youngest child who committed suicide was an 11-year-
ence of a suicide note and/or suicide attempts/threats was old boy. Overall female incidence was 37% (31.6% in the
 TUGALEVA ET AL. . RETROSPECTIVE ANALYSIS OF HANGING DEATHS 3

younger population, 14 years of age or younger and 40.7% in deceased were males. An additional case of somewhat atypical
older children, 15 or older). The proportion of cases (63%), with autoerotic death was documented in a 19-year-old man who was
a positive psychiatric history (mostly depression, behavioral dis- found hanging by a dog leash from a set of stairs with no typical
orders, personality disorders, and substance abuse), was lower self-release mechanism involved. A pornographic story involving
than in the overall population (78.6%) although less common in hanging was found on his computer. The death was concluded
the younger group (52%) than in older children (70.3%). The to be accidental. No other cases of autoeroticism were reported
frequency (54%) of prior suicidal tendencies (suicide note, during the studied time period.
attempt, or threat) was slightly higher than overall population
(49.5%). The frequency of prior attempts (30%) and suicide Combined Suicide—In two cases, another method of suicide
notes (19.6%) was similar to the overall population. Although was employed. In the first case, a 45-year-old man was found
the frequency of prior attempts was similar in younger and older hanging in a barn with a gunshot wound to his forehead and a rifle
children, threats were over three times more common in younger nearby. Further scene investigation and autopsy findings verified a
children. Suicide notes were found only in older group. The self-inflicted, but not necessarily fatal gunshot wound. The bullet
youngest child who left a suicide note was a 15-year-old girl. penetrated the right frontal lobe of his brain. In the second case, a
37-year-old man was found hanging from a ceiling beam in his
Psychiatric Inpatients—Seventeen deceased were inpatients in garage. The deceased had an entrance wound to his temple. A .22-
a psychiatric ward at the time of the incident. Four of them were caliber rifle was present at his feet. A penetrating gunshot wound
away from the hospital (i.e., leave of absence/weekend pass), track shattered the base of his skull and perforated through the
and one patient escaped from a psychiatric facility. Six of the bilateral basal frontal and right temporal poles and anterior pons.
patients were resuscitated (with a survival time of 2–135 days). Cause of death was concluded to be a combination of the gunshot
wound to the head and hanging. In another case, a loaded rifle was
Deaths in Custody—In our study, 21 decedents were in cus- present at the scene which the victim likely contemplated on using
tody at the time of the incident. All of them were males with a if the hanging attempt was unsuccessful.
mean age of 33.6 years. Positive prior psychiatric history was
recorded in all cases including five instances of diagnosed Restraints—In 17 cases, the deceased restrained themselves
depression. Near half of the deceased (10 cases) had prior single by applying a ligature (same as used for hanging, a different
or multiple suicide attempts (three by hanging) and documented rope, or duct tape) to their wrists and/or ankles. All of the
suicidal threats (11 instances). Suicide notes were present in a deceased were males with average age of 38.1 years (from 16 to
third of the cases (seven cases). All known suspension types (17 66 years). All cases were concluded to be suicides. In 10 of the
cases) were incomplete. The most common ligatures were bed cases, only the wrists were bound (including two cases in which
sheets (14 cases), which were either intact or torn into strips, handcuffs were applied), in three cases, only ankles were bound,
and items of clothing (four cases where shoelaces, overalls, or and in four cases, both wrists and ankles were tied.
socks were used to form a ligature). In only two cases, there
were more “conventional” type ligatures used (i.e., an electric Other—In four cases, the male victims placed a plastic or fab-
cord, a cable from exercise equipment). In all but one case, the ric bag over their heads. The bag application did not interfere
manner of death was ruled as suicide. In that one case, the man- with breathing (excluding suffocation as a mechanism). Three
ner was undetermined, that is, either suicide or accident. Regard- cases involved two females and one male who covered their
ing the latter manner, in addition to the history of multiple prior faces with some sort of fabric material. One male stuffed under-
suicide attempts, the deceased had more recently expressed wear into his mouth. Another male had a large amount of plastic
intent to fake a suicide attempt. Four individuals survived fol- material taped in place over his mouth and inside his oral cavity.
lowing resuscitation, from 34 h to 26 days. One female had a scarf stuffed into the oral cavity. In four cases,
the deceased were wearing earphones or had earplugs (two
Hanging Inside a Vehicle—There were two incidents of suici- males and two females).
dal hanging inside a vehicle. A 57-year-old man was found in
the back of his pickup truck suspended from the support ribs of
Seasonal Variation
the rear cab by a belt and slumped backwards. The other, a 60-
year-old man, was found hanging in the rear of his van sus- Case distribution by month is shown in Fig. 2, combined for
pended by a dog leash attached to a coat hook. the studied two-year period. When each year was analyzed sepa-
rately, hangings were most frequent in the spring of 1998 and in
Double Suicide—Two incidents of double suicide were docu- the summer of 1999. For both years, the greatest number of
mented. The first involved two 13-year-old girls suspended from hangings occurred in May.
garage rafters by the opposite ends of the same electric cord. In the
other dual suicide, the deceased were a 59- and 27-year-old father
Other Injuries
and son suspended from different rafters by the same rope.
In addition to the two above-described cases of firearms inju-
Murder–Suicide—In addition to the above-described two ries, a number of other injuries were present, the most common
instances of mother–child hanging deaths, there was a case of a being blunt force trauma (179 cases, 28.3%), predominantly
deceased who took his own life shortly after he stabbed his victim. recent and minor.
In three cases, significant trauma was sustained as a result of
Autoerotic Behavior—Five of the deceased were found naked. a fall from a broken noose. In one case, a 39-year-old man (Case
Four of the cases were determined to be suicides. The manner of 5 in Table 5) jumped from a 4.5- to 6-meter-high bridge with an
death for one case remained undetermined because suicide or aircraft cable tied around his neck and the other end of the cable
accident (potential autoerotic asphyxiation) was possible. All the secured to the bridge railing. As a result, he sustained a deep
4 JOURNAL OF FORENSIC SCIENCES

100
levels of medications (mostly above therapeutic levels of pre-
scribed antidepressants). Toxicological testing was negative or
showed below/therapeutic medication levels in 39.8% of the
80
cases.
NUMBER OF CASES

Hanging-Related Neck Injuries

60
Hyoid and Laryngeal Fractures—Fractures of the hyoid bone
and/or laryngeal cartilages were reported in 46 cases (7.3%) of
40 632 cases where complete postmortem examination was under-
taken. The most common was an isolated hyoid fracture (30
cases, 4.7%). Thyroid cartilage was fractured in 10 cases (1.6%).
20 In three cases (0.5%), both the hyoid bone and the thyroid carti-
lage were fractured. Cricoid fractures were observed in three
cases (0.5%). Very limited information was available on the lat-
0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
ter cases: a 37-year-old woman hanging in a small space behind
MONTH a furnace; a 36-year-old man completely suspended with a thin
ligature; and a 27-year-old man suspended with a nylon rope
FIG. 2––Seasonal case distribution. with his feet touching the floor. Apart from the recent incised
wrist wounds in the second case, no other injuries were docu-
laceration to the anterior neck with a complete transection of the mented.
trachea, esophagus, and cervical spine. The ligature broke, and Fractures of the left greater horn of the hyoid bone were
the deceased was found on rocky ground, partially submerged in observed more frequently (17 cases vs. nine cases where the
a creek. He had scalp lacerations with extensive skull fractures right horn was broken). In three cases, hyoid horns were frac-
and cerebral contusions resulting from the fall. Although fall- tured bilaterally, and in the remaining four cases, no comment
related trauma was significant and potentially fatal, he died from was made regarding the site of fracture. Right and left superior
severe neck trauma as a result of hanging. In addition to severe thyroid horns were fractured with the same frequency (three
head trauma, there were pulmonary contusions and a retroperi- cases for each side) and in four cases bilaterally. In one case,
toneal hematoma. In the second case, a fall from a broken liga- there was no comment identifying the site of injury. The lamina
ture in a long drop case was associated with significant of the thyroid cartilage was fractured in two cases. In three
perimortem abdominal trauma including retroperitoneal hema- cases, a complete transection of airways occurred.
toma, lacerated liver, and adrenal gland with small hemoperi- Hemorrhage at the fracture site was described in 14 instances
toneum (Case 3 in Table 5). In the third case, a fall from a of hyoid and seven of thyroid cartilage fractures, and was absent
broken noose in the first unsuccessful hanging attempt resulted in three and four cases, respectively. In the remaining 16 cases
in significant nonfatal head trauma including a parietal scalp lac- of hyoid fractures and two cases of thyroid fractures, no com-
eration with a skull fracture, contrecoup type cerebral contusions, ment was made regarding the presence or absence of associated
and mild acute subarachnoid hemorrhage. hemorrhage. In three cases of cricoid cartilage fractures, no clari-
Self-inflicted fresh incised wounds were observed in 42 fication was provided whether the injury was hemorrhagic.
(6.2%) suicides (wrists and forearms—36, neck—4, anterior The incidence of fractures was higher in the older age groups
chest—1, lower extremities—1). One of the neck wound cases (Table 1). Frequency of both laryngeal and hyoid fractures was
also had a stab wound to the neck. Recent/healing neck incised significantly higher when older than 30 (p = 0.049).
wounds were observed in two cases. Scars from prior cuts to Fractures were significantly more common (p = 0.028) in
wrists and forearms were present in 61 cases. Two cases of heal- males than females (Table 2). When stratified by age, no frac-
ing stab wounds to the left chest were documented. All chest tures in females younger than 30 years were observed. There
and neck sharp force injuries were consistent with being self- was a 3.8% incidence in older women. Respective incidences for
inflicted and nonfatal and present in males only. Fresh and old males younger or older than 30 years were 5.2% and 9.7%.
cuts to extremities were more common in females. Although the incidence of both hyoid and thyroid fractures was
In addition to the defined ligature mark to the neck, there much higher in males, one of three cricoid fractures was found
were abrasions along the ligature mark in 43 cases and bruises in a female.
along the mark in four cases (in two instances in addition to When the distribution of neck injuries was evaluated in rela-
abrasions). In two cases, there were superficial tears along the tion to the different institutions, the highest incidence was in
ligature marks (one in a long drop and the second in an incom- teaching hospitals (16.7%) and the lowest in the Provincial
plete hanging of a teenager). In 10 cases, there were nonspecific Forensic Pathology Unit (PFPU) (2.8%). The incidence was
abrasions to the neck away from the mark and in five cases— 6.1% in community hospitals. The proportion of autopsied
bruises. Two cases of distinct fingernail marks were documented females was the highest in the PFPU (35.2%) and the lowest in
(both in males). All cases with the above additional neck find- teaching hospitals (14%). The higher proportion of autopsied
ings were suicides. females in PFPU was skewed because of the more frequent
external examinations performed in the Unit. In nearly half of
the hanging deaths, postmortems were limited to external exami-
Toxicological Findings
nations only, and most of them (93.8%) were performed on
Toxicologic testing was not performed in 23.6% of the cases. males. The mean age of the individuals who had complete
In the suicidal hangings, 31.3% tested positive for ethanol and/ autopsies was 41.4 and 39.1 years in the PFPU and teaching
or illegal drugs and 5.3% showed toxicologically significant hospitals, respectively.
 TUGALEVA ET AL. . RETROSPECTIVE ANALYSIS OF HANGING DEATHS 5

TABLE 1––Distribution of laryngeal and hyoid fractures by age groups. TABLE 3––Distribution of laryngeal and hyoid fractures by weight.

Fractures Fractures

Age Groups No Yes Total Cases Weight No Yes Total Cases

0–9 years 5 0 5 < 50 kg 30 0 30
100% 0% 100% 100% 0% 100%
10–19 years 64 1 65 50–59 kg 76 4 80
98.5% 1.5% 100% 95% 5% 100%
20–29 years 114 7 121 60–69 kg 181 12 193
94.2% 5.8% 100% 93.8% 6.2% 100%
30–39 years 144 14 158 70–79 kg 128 10 138
91.1% 8.9% 100% 92.8% 7.2% 100%
40–49 years 108 9 117 80–89 kg 84 12 96
92.3% 7.7% 100% 87.5% 12.5% 100%
50–59 years 76 7 83 ≥90 kg 77 8 85
91.6% 8.4% 100% 90.6% 9.4% 100%
60–69 years 36 4 40 Unknown 10 0 10
90% 10% 100% 100% 0% 100%
70–79 years 22 2 24 Total cases 586 46 632
91.7% 8.3% 100% 92.7% 7.3% 100%
80–89 years 16 2 18
88.9% 11.1% 100%
≥90 years 1 0 1
100% 0% 100% TABLE 4––Distribution of laryngeal and hyoid fractures by BMI.
Total cases 586 46 632
92.7% 7.3% 100%
Fractures

BMI No Yes Total Cases

Underweight (<18.5) 35 2 37
TABLE 2––Distribution of hyoid, thyroid, and cricoid fractures by gender. 94.6% 5.4% 100%
Normal (18.5–24.9) 338 20 358
Fractures 94.4% 5.6% 100%
Overweight/Obese (≥25) 203 24 227
Gender Hyoid Thyroid Combined Hyoid/Thyroid Cricoid Total 89.4% 10.6% 100%
Unknown 10 0 10
Male 32 12 3 2 43 100% 0% 100%
6.2% 2.3% 0.5% 0.4% 8.4% Total cases 586 46 632
Female 1 1 0 1 3 92.7% 7.3% 100%
0.8% 0.8% 0% 0.8% 2.5%
Total 33 13 3 3 46
5.2% 2.1% 0.5% 0.5% 7.3%
indentation/abrasion mark, and internal neck structures were
intact.
Distribution of laryngeal and hyoid fractures in relation to
weight and body mass index (BMI) is shown in Tables 3 and 4, Cervical Spine Injuries—Seven cases with cervical spine inju-
respectively. No fractures were observed in individuals lighter ries were identified including fractures, dislocations, and com-
than 50 kg. The difference in the incidence was significant for plete spine transections (Table 6). In addition, there was a case
the weight above 80 kg (p = 0.026). Overall, the incidence of where the hospitalized victim died shortly after a hanging inci-
laryngeal and hyoid fractures in the deceased with normal or dent and had a radiologically documented avulsion of C2 verte-
below normal BMI was half that in the overweight and obese bra. The latter case was not included, because no autopsy was
population (p = 0.022). When stratified by age (below/above performed. The incidence of cervical spine injury was 1.1%,
30 years), the difference remained significant for BMI being twice more prevalent in individuals older than 50 years
(p = 0.026) but not for body weight (p = 0.09). (0.9% vs. 1.8%). All but one of the deceased were males. The
female victim had preexisting marked osteoporosis. The inci-
Long Drop Hangings—Eighteen cases of a definitive long dence of cervical spine trauma was higher in individuals whose
drop were identified. These would be designated as “long drops” weights were equal to or above 80 kg or whose BMI was above
if following the criteria of the Official Table of Drops by the normal range.
British Home Office (for judicial punishment), taking into con-
sideration the recorded weight of the deceased and the length of Soft Tissue Injuries—Hanging-related soft tissue injuries were
rope to drop into a hanging position. The incidence of laryngeal variable in severity, ranging from minute soft tissue hemorrhages
and hyoid injuries was 22.2% (four cases), which was signifi- to complete transection of the neck structures (above-mentioned
cantly higher (p = 0.013) in comparison with non-long drop cases of long drop hangings). Soft tissue injuries not associated
cases. More detailed information on those victims who sustained with skeletal trauma (away from fractured or disrupted neck
hyoid/laryngeal trauma is shown in Table 5 (cases 1–4). Case 5 structures) were reported in 59 cases (9.3%). In 10 of the cases,
had transection of the upper airway at the level of trachea and injuries were observed in more than one location. The majority
upper cervical spine with intact hyoid and laryngeal structures. (52 instances) were hemorrhages within the neck strap muscles,
In Case 6, there were superficial lacerations along the ligature soft tissues along the ligature mark, or around intact laryngeal
mark. In the remainder of the cases, there was an unremarkable structures. Intimal carotid tear was reported only in one instance.
6 JOURNAL OF FORENSIC SCIENCES

TABLE 5––Long drop hanging cases.

Case Ligature
No. Sex Age Weight Drop Height Ligature Material Width Knot Position Neck Injuries
1 Male 36 81 kg 2.5 m Nylon rope 1.9 cm Right side Near decapitation through C2–C3 disk; only small amount
of posterior neck soft tissue left; hyoid fracture
2 Male 16 93 kg 4.5 m Heavy thick rope Unknown Left side Complete transection of larynx and partial transection
of esophagus
3 Male 42 Average 3–4.5 m Fiber rope 0.5 cm Right side Fracture of left superior thyroid horn
4 Male 54 72 kg 2–2.5 m Nylon rope 0.8 cm Left side Fracture of right hyoid horn
5 Male 39 80 kg 4.5–6 m Aircraft steel cable Unknown Unknown Large anterior neck laceration; transection of trachea
and esophagus; complete cervical spine/cord transection
through C2–C3 disk
6 Male 62 100 kg 2m Steel cable Unknown Right side Lacerations/stretch-like marks above the main ligature mark

TABLE 6––Cervical spine injuries.

Suspension Long
Case no. Sex Age Weight Type Drop Ligature Knot Position Spine Injuries
1 Male 27 82 kg Incomplete No Bed sheet Unknown C1–C2 subluxation
2 Female 83 79 kg Unknown No Nylon rope and Left posterolateral Transverse C5–C6 fracture; marked osteoporosis
macram
e strings neck
3 Male 21 80 kg Incomplete No Nylon rope Behind right ear Hangman’s fracture on postmortem radiographs
4 Male 63 122 kg Incomplete No Nylon rope Below chin C1–C2 subluxation
5 Male 87 Average Unknown No Turban Unknown Anterior vertebral C7–T1 fracture
6 (Case 1, Male 36 81 kg Complete 2.5 m Nylon rope Right side Near decapitation through C2–C3 disk with
Table 5) spinal cord transection
7 (Case 5, Male 39 80 kg Complete 4.5–6 m Aircraft steel cable Unknown Complete cervical spine and cord transection
Table 5) through C2–C3 disk

In addition, there were eight cases of perivascular hematomas and was prominent in ours (comparative data between studies
with no grossly apparent vascular tears, and a case of a torn presented in Table 7). The youngest individual to commit sui-
epiglottis. In two cases, there were unilateral and bilateral tears cide in this study was an 11-year-old boy, while 10-year-old
of the sternocleidomastoid muscles (level not described). In addi- individuals were reported in other studies (12,17). A majority
tion, there were seven cases of tongue injuries (hemorrhages and of the suicide victims (78.6%) had a prior psychiatric history
bite marks). with half of them having a history of prior suicidal tenden-
cies, prevalence higher than in other studies (31,32).
Role of Suspension Type—Information on the type of suspen- Although a vast majority of hanging deaths are suicides,
sion was available for 57.6% of the autopsies (364 cases). Approx- accidental hangings and homicides have also been reported.
imately one-third of these (33.5%) were reported as complete Accidental hangings are uncommon, occurring up to 5% of all
suspensions. The remainder (66.5%) of the deceased were incom- hanging fatalities (33) and usually involve entanglement of
pletely suspended. The incidence of laryngeal and hyoid fractures small children in ligatures while playing (30,34), experimental
was higher when suspension was complete (10.7% vs. 6.2%). A behavior involving ligatures in older children (30,34), misad-
similar tendency was observed for cervical spine injuries—the ventures in adults frequently related to unsafe surrounding envi-
incidence was twice greater in completely suspended individuals ronment and intoxication (35,36), or autoerotic asphyxiation in
(1.6% vs. 0.8%). Soft tissue injuries unrelated to skeletal fractures younger males (30,37). Of nine accidental deaths (1.2%) in our
were more common in incomplete suspensions (11.6% vs. 9.8%). study, a majority (six) involved children. Accidental hangings
When the group of complete suspension cases was subdivided in adults were related to entanglement in a ligature following
into an “intermediate” group consisting of individuals whose feet medical collapse and a fall. One accidental hanging involved a
had a partial contact with the ground (toes/feet touching the young male with apparent erotic intent, yet lacking an escape
floor), this subgroup showed a similar distribution for all types mechanism. No classical cases of autoerotic asphyxiation were
of injuries when compared to the complete suspension group. observed during the studied time period.
Homicidal hangings are extremely rare and should be distin-
guished from postmortem body suspension following a homicide
Discussion
by other methods (1–6). Homicidal hangings are reported in
Hanging is one of the most common methods of committing young children. When adults are involved, there are usually
suicide. Numerous studies have been published regarding the signs of violence or incapacitation. In our study, two cases of
demographic parameters of hanging victims and the various homicidal hanging were identified, both involving young girls
pathological findings observed in the course of postmortem suspended by their mothers who had further taken their own
examination. lives by hanging (dyadic murders).
The typical hanging victim is a young or middle-aged male A seasonal variation in suicides has been reported in several
with a history of prior mental illness and suicidal tendencies past studies which show that suicides peak in spring and early
who is found suspended in a secure location. Male predomi- summer and dwindle in autumn and winter months (38–40).
nance has been demonstrated in a number of previous studies Hanging deaths show distinct patterns and cycles. Annual
 TABLE 7––Literature review—population demographics and incidence of hanging-related neck injuries.

Incidence of Neck Injuries

Cervical Larynx or
Reference Year Design Cases Mean Age Male % Thyroid (%) Hyoid (%) Both (%) Cricoid (%) Spine (%) Hyoid (%)
Taktak et al. (12) 2015 Retrospective 4502 37.8 73.2 21.9 16.9 13.5 – 444 (9.9) 52.3
Hassan et al. (13) 2013 Retrospective 118 – 73 12.7 19.5 9.3 – 3 (2.5) 41.5
Jayaprakash and Sreekumari (14) 2012 Prospective 189 – 70.9 5.3 2.7 – 1 (0.5) 3 (1.6) 8.5
Godin et al. (7) 2012 Retrospective 231 34.5 84 18.6 2.6 2.2 0 – 23.4
Meta-analysis 2700 – – – – – 1 – 36.6  24.7
Cl
ement et al. (15) 2011 Retrospective 206 35.4 for male 83.5 22 1 5 0 – 28
31.4 for female
Su
areɀ-Pe~naranda et al. (16) 2008 Retrospective 228 51.65 77.8 47.1 (all) 48.4 (all) 0 8 (3.6) 75.3
Uz€
€ un et al. (17) 2007 Retrospective 761 – 70.6 21.4 23.3 14.5 – 10 (1.3) 59.2
Azmak (11) 2006 Retrospective 56 41.6 83.9 17.9 46.4 12.5 – – 76.8
Sharma et al.(18) 2005 Retrospective 55 28.96 71 3.6 1.8 3.6 0 0 9.1
Prospective 53 11.3 3.8 5.7 0 0 20.8
Nikolic et al. (19) 2003 Retrospective 175 47.33 76 42.9 18.9 2.9 – 3 (1.7) subluxation 64.7
Green et al. (20) 2000 Prospective 40 35 82.5 22.5 10 15 0 0 47.5
TUGALEVA ET AL.

Feigin (21) 1999 Retrospective 307 – 90 4.9 2.9 1 0 3 (1) fractures 8.8
Khokhlov (22) 1997 Prospective 137 82 54.7 (all) 42.3 (all) 27.7 13 (9.5) 76.6
.

– –
Morild (23) 1996 Prospective 80 38.7 73 10 13.8 2.5 0 – 26.3
Samarasekera and Cooke (24) 1996 Prospective 233 – 88 30 7 8 1 (0.4) 1 (0.4) fracture 45.4
Betz and Eisenmenger (25) 1996 Retrospective 109 – – 25.7 (single site—hyoid or thyroid); – – 67
41.3 multiple
James and Silcocks (26) 1992 Retrospective 84 45 91.7 20 12 5 0 0 36
Simonsen (27) 1988 Prospective 80 53 for male 60 27.5 8.8 8.8 0 – 45
52 for female
Luke et al. (28) 1985 Prospective 61 41.3 84 3.3 13.1 9.8 0 0 26.2
Paparo and Siegel (29) 1984 Retrospective 160 – 76 10.6 6.3 2.5 1 (0.6) – 20
Prospective
Polson and Gee (30) 1973 – 80 – – 30 8.8 16.3 – – 55.1
Our Study Retrospective 632 39.8 81.3 1.6 4.7 0.5 3 (0.5) 7 (1.1) 7.3
RETROSPECTIVE ANALYSIS OF HANGING DEATHS
7
8 JOURNAL OF FORENSIC SCIENCES

fluctuation was found to vary across countries with Canada A higher incidence of neck fractures was observed among
showing the least prominent seasonal fluctuations (38). Some males, a tendency similar to most prior studies
seasonal variation in hanging deaths was observed in our study (7,15,18,20,24,27). A difference in the patterns of ossification
with the highest incidence in May. Azmak (11) and Morild (23) between males and females is thought to be a factor with
demonstrated a peak in spring–summer while other studies females having a slower rate of ossification. The patterns of ossi-
(17,26,27) found no correlation. Interestingly, Guarner et al. (31) fication between genders, in general, diverge around the fifth
found hanging fatalities highest in December. decade of life (51).
Among the studied cohort, a number of unusual cases were Gender difference in fracture incidence was further demon-
reported. Unusual circumstances will often raise suspicion of strated when evaluating different institutions performing medi-
foul play (41–44). Among these are combined suicides (also colegal autopsies in Ontario. The difference in the frequency of
called complex suicides) where multiple, frequently extreme, neck injuries was most significant between the PFPU (2.8%) and
methods of suicide are employed to protect against failure. We the teaching hospitals (16.7%). The PFPU had the highest pro-
observed two cases of unusual combined suicides where both portion of autopsies on female victims.
hanging and firearms were involved. Nonlethal fresh incised In addition, there was a tendency for fractures to increase in
wounds and intoxication are not unusual findings in cases of sui- heavier individuals. Incidence correlated with both body weight
cidal hanging (12,42), and were observed in 6.2% and 36.6% of and BMI. A recent study performed by Clement et al. (15)
cases in this study, respectively. demonstrated a contributory role of weight, height, and BMI in
Rarely, restraints (wrist/ankle bounding) are used by the the incidence of fractures, with the difference remaining signifi-
deceased to prevent self-rescuing attempts (45,46). Occasional cant when correlated with the age.
cases of a mouth plug (likely in an attempt to prevent a cry for Eighteen unequivocal long drop hangings were identified
help) are described (46,47). These cases raise suspicions of other within our studied group. These showed a higher incidence of
party involvement and require further investigation. We identi- hyoid–laryngeal fractures.
fied 17 suicidal hanging cases where hands and/or ankles were The contributory role of suspension type was both confirmed
bound and three instances of an oral plug. (15,18,23,24,28) and rejected (21,26,29) in previous studies.
Suicide pacts are rare, especially involving hanging (48). Dif- Luke et al. (28) concluded that complete suspension was a con-
ficulty might arise in determining the manner of death. Two tributing factor to fractures irrespective of age. We found it chal-
cases of double suicide, one involving teenage girls and the lenging to assess the data on suspension. The main challenges
other involving two male family members, were identified in our were related to initial scene alteration by the finder of the body
study. Unusual places of hanging can also raise suspicion. For and incomplete case information. Additional uncertainty came
example, rare cases of hanging inside a vehicle were reported in from the fact that incomplete hanging might be, in fact, an evo-
the literature (49,50). Our study identified two suicidal hangings lution of complete suspension where the ligature was further
in a car. stretched or the knot tightened under the effects of gravitational
The frequency of laryngeal/hyoid fractures in the literature forces in a completely suspended individual (52). To further
ranges from 0% to 76.8% (9–11). This discrepancy is attributed explore this, the cases where the feet of the deceased were only
to variable population composition, lack of standard dissection in partial contact with the ground were analyzed separately. This
approach, different postmortem techniques employed (e.g., radio- group showed tendencies similar to the complete suspension
logical or stereomicroscopic examination), thoroughness of group in relation to both skeletal and soft tissue injuries.
assessment, and retrospective vs. prospective design of the study. Although we did find fractures to be more common in complete
The frequency of laryngeal and hyoid fractures in our study was suspension and soft tissue injuries more frequent in incomplete
significantly lower than in other studies. This difference could suspension, the assessment was limited by missing data. The
be explained as combined effect of all of the above factors. predominance of incomplete suspensions in this series might be
Fractured structures can be easily overlooked at autopsy (30). another factor to account for the lower incidence of neck inju-
Visual inspection and palpation alone miss a significant number ries. In Azmak’s study (11), the frequency of neck injuries was
of injuries, and on occasion may lead to a false diagnosis of the highest (76.8%). Most of the cases in that study (96.4%)
fracture (22,30). Layered anterior neck dissection in an avascular were complete suspensions.
field (“dry neck” technique) with a careful dissection of hyoid– The nature and relative position of the ligature and knot were
larynx complex is generally accepted as an approach that yields reported to play a role in some studies (18,24–27) and found
the most reliable results. The retrospective nature of this study, noncontributory in others (15,19,21,28,29). These factors were
however, did not allow us to evaluate the role of dissection not analyzed in the present study due to a lack of complete data.
techniques in determining the incidence of fractures. The Other factors that are potentially important such as the static vs.
autopsy reports documented use of a “dry neck” approach in a dynamic nature of the force applied during neck constriction
small percentage of cases (9%) including only two cases with (28,53) (slow neck compression vs. “jumping” into a noose)
fractures. could not be assessed in the present study.
Like most of the other studies, we observed the incidence of One unusual finding in our study was a higher incidence of
fractures to increase with age (7,14,15,17–21,23,24,26–29). The cricoid fractures than reported in the literature. Cricoid fracture
age dependence is likely based on age-related fusion of the is considered very unusual for suicidal or accidental hanging,
hyoid joints, calcification and ossification of the laryngeal carti- with only a few cases reported (14,24,29), while its incidence in
lages, and overall brittleness of bony structures with an older homicidal strangulation ranges between 5% and 20.6% (7). A
age. Hyaline thyroid and cricoid cartilages undergo calcification recent study by Godin et al. (7) specifically related to the com-
and ossification processes starting from the second decade and parative incidence of cricoid fractures in suicidal hangings vs.
advancing with age (51). Variations in ossification, however, do homicidal strangulation deaths found only one instance of cri-
exist based on other factors than age (individual health, genetics, coid fracture among 2700 cases from previously published stud-
etc.) (51). ies. This injury was proposed as highly suspicious and a
 TUGALEVA ET AL. . RETROSPECTIVE ANALYSIS OF HANGING DEATHS 9

potential indicator of homicide. In Khokhlov’s study (22), the from injuries of concealed homicidal strangulation with post-
frequency of cricoid fractures in hanging was reported as 9.5% mortem body suspension.
(13 cases). In his prospective study, the author employed stere- Presence of other trauma was identified in a number of cases,
omicroscopic examination of carefully skeletonized hyoid and mostly minor blunt force injuries. Significant trauma related to a
larynx specimens and found that the majority of cricoid injuries fall from a hanging position (broken ligature) was present in
were apparently inconspicuous (“fissures”). only three cases.
Hemorrhage around a fracture site in the larynx or hyoid
bone is a sign that trauma occurred while the individual was
alive. In our study, 43% of fractures were associated with Conclusion
hemorrhages while 14% were nonhemorrhagic. While some Because the large majority of hanging deaths are suicides,
studies identify hemorrhages at all fracture sites (12,17,22), determination of cause and manner of death is usually straight-
absence of vital reaction is not uncommon. Luke et al. (28) forward. On occasion, they can be a challenge when suspicions
found near half of detected fractures lacked soft tissue hemor- of foul play are raised. Deaths occurring under special (e.g.,
rhage, which they attributed to possibly compromised circula- deaths in custody or in a psychiatric facility) or unusual circum-
tion at the fracture site due to locally increased pressure and stances (very young victims, young individuals without a history
arterial compromise. Morlid (23) and Simonsen (27) concluded predictive of suicide, young women in an unsecure environment
that fractures often were not associated with hemorrhages. discovered by a male partner, use of restraints or gags, autoerotic
Both studies demonstrated some increase in the frequency of deaths, double suicides, uncommon locations such as motor
fractures with increasing length of suspension time, suggesting vehicles, combined/complex suicides) were found in this study.
that many fractures might be postmortem. Other proposed Such cases place the onus on the death investigation team to rule
explanations for the absence of hemorrhage at a fracture site out foul play. Depending on the circumstances, there may be
include the terminal events at the time of death (e.g., terminal public demands for prevention of future deaths and even recom-
convulsive episode), postmortem body handling (ligature pense through legal avenues. The current approach to hanging
removal, body transportation, etc.), or technical artifact created deaths in forensic pathology practice is the increasing use of
by neck dissection (20,23,29). Green et al. (20) found frac- external examinations. Cases with complete autopsies tend to be
tured neck structures in near half of their 40 prospectively skewed to deaths occurring under special and unusual circum-
studied cases, yet only one with unequivocal hemorrhage. The stances. This study reinforces previous literature in noting that
same study showed no postmortem dissection-related fractures the presence and frequency of external and internal neck trauma
in their control group supporting their conclusion that dissec- are determined by a complex interplay of multiple factors of
tion techniques were unlikely responsible for the fractures. variable significance such as age, gender, body habitus, and
Rajs and Thiblin (54) studied histological appearance of frac- degree of suspension. Notably, this study showed that no frac-
tured thyroid cartilage and demonstrated that hemorrhages at tures occurred in females younger that thirty years of age.
fracture sites were not always macroscopically evident; Although cricoid fractures were rare and only observed in three
hemorrhage was diagnosed microscopically in about third of suicides, one was found in a woman. As reported in other litera-
the fractures. ture on suicidal hangings, this study noted external trauma
Cervical spine injuries are considered rare in suicidal hanging remote from the ligature mark not only on the neck but also on
(55) ranging from 0% to 9.9% (Table 7). They are more com- other areas of the body. Other unusual internal neck injuries
mon in judicial type hanging where long drop is a factor. (e.g., cervical spine trauma) were observed. Our observations do
Review of historical judicial hangings showed a variable propor- provide reassurance to the forensic pathologist that a spectrum
tion of cases having cervical injuries at various levels with the of injuries can occur in suicidal hangings. Their ultimate signifi-
classical hangman’s fracture (C2 fracture dislocation through cance in terms of manner of death is predicated by the totality
bilateral pars interarticularis) being uncommon (56,57). In our of the death investigation.
study, seven cases of cervical spine injuries (fractures or disloca-
tions) were documented, mostly involving the upper cervical
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