State Firearm Laws and Firearm-Related Mortality and Morbidity

This Viewpoint highlights the challenges to passing federal legislation that limits gun ownership and accessibility and summarizes some of the state laws used to successfully lower rates of firearm-related death and injury.

Examining the Impact of Firearm Safety Laws on Suicides

This Medical News feature discusses what’s known about the impact of firearm safety laws on suicide rates.

Accelerating Research on Suicide Risk and Prevention in Women Veterans Through Research-Operations Partnerships

BACKGROUND

Suicide rates for women veterans are increasing faster than for nonveterans. The 2017 suicide rate for women veterans was more than double that for women nonveterans. However, research to inform improved suicide prevention for women veterans is scant.

OBJECTIVES

To accelerate research on women veterans' unique risks and resiliencies for suicide, the Department of Veterans Affairs (VA) Women's Health Research Network launched a Women Veterans Suicide Prevention Research Work Group to target technical support for researchers, promote collaboration with national VA program offices, and ultimately increase dissemination and translation of research into clinical practice, public health strategies, and policies. The objective of this paper is to report on the process and outcomes of the Work Group's strategic planning efforts to identify and fill gaps in suicide prevention research among women veterans.

METHODS

An in-person meeting of 20 researchers and operational leaders was convened to summarize existing research evidence and identify research priorities and challenges.

RESULTS

Research priorities included civilian reintegration, community connections, psychosocial stressors (eg, social determinants of health) and trauma, risk assessment, clinical interventions, upstream prevention, and health care access. The importance of increasing evidence on gender differences and for women veterans not using VA health care was emphasized.

CONCLUSIONS

Research to inform suicide prevention tailored to meet women veterans' needs is essential; however, many priorities and challenges remain unaddressed. Although Work Group efforts have achieved funding gains, further work to formalize, promote and meet the demands of a suicide prevention research agenda for women veterans requires is ongoing focus.

What is suicide? Classifying self-killings

Although the most common understanding of suicide is intentional self-killing, this conception either rules out someone who lacks mental capacity being classed as a suicide or, if acting intentionally is meant to include this sort of case, then what it means to act intentionally is so weak that intention is not a necessary condition of suicide. This has implications in health care, and has a further bearing on issues such as assisted suicide and health insurance. In this paper, I argue that intention is not a necessary condition of suicide at all. Rather, I develop a novel approach that deploys the structure of a homicide taxonomy to classify and characterise suicides to arrive at a conceptually robust understanding of suicide. According to my analysis of suicide, an agent is the proximate cause of his death. Suicide is 'self-killing,' rather than 'intentional self-killing.' Adopting this understanding of suicide performs several functions: (1) We acquire an external standard to assess diverging analyses on specific cases by appealing to homologous homicides. (2) Following such a taxonomy differentiates types of suicides. (3) This approach has application in addressing negative connotations about suicide. (4) As a robust view, adding intention is an unnecessary complication. (5) It is more consistent with psychological and sociological assessments of suicide than 'intentional self-killing.' (6) It has useful applications in informing public policy. This paper's focus is on classifying types of suicides, rather than on the moral permissibility or on underlying causes of suicidal ideation and behaviour.

Means restriction for the prevention of suicide by jumping

BACKGROUND

Jumping from a height is an uncommon but lethal means of suicide. Restricting access to means is an important universal or population-based approach to suicide prevention with clear evidence of its effectiveness. However, the evidence with respect to means restriction for the prevention of suicide by jumping is not well established.

OBJECTIVES

To evaluate the effectiveness of interventions to restrict the availability of, or access to, means of suicide by jumping. These include the use of physical barriers, fencing or safety nets at frequently-used jumping sites, or restriction of access to these sites, such as by way of road closures.

SEARCH METHODS

We searched the Cochrane Library, Embase, MEDLINE, PsycINFO, and Web of Science to May 2019. We conducted additional searches of the international trial registries including the World Health Organization International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov, to identify relevant unpublished and ongoing studies. We searched the reference lists of all included studies and relevant systematic reviews to identify additional studies and contacted authors and subject experts for information on unpublished or ongoing studies. We applied no restrictions on date, language or publication status to the searches. Two review authors independently assessed all citations from the searches and identified relevant titles and abstracts. Our main outcomes of interest were suicide, attempted suicide or self-harm, and cost-effectiveness of interventions.

SELECTION CRITERIA

Eligible studies were randomised or quasi-randomised controlled trials, controlled intervention studies without randomisation, before-and-after studies, or studies using interrupted time series designs, which evaluated interventions to restrict the availability of, or access to, means of suicide by jumping.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion and three review authors extracted study data. We pooled studies that evaluated similar interventions and outcomes using a random-effects meta-analysis, and we synthesised data from other studies in a narrative summary. We summarised the quality of the evidence included in this review using the GRADE approach.

MAIN RESULTS

We included 14 studies in this review. Thirteen were before-and-after studies and one was a cost-effectiveness analysis. Three studies each took place in Switzerland and the USA, while two studies each were from the UK, Canada, New Zealand, and Australia respectively. The majority of studies (10/14) assessed jumping means restriction interventions delivered in isolation, half of which were at bridges. Due to the observational nature of included studies, none compared comparator interventions or control conditions. During the pre- and postintervention period among the 13 before-and-after studies, a total of 742.3 suicides (5.5 suicides per year) occurred during the pre-intervention period (134.5 study years), while 70.6 suicides (0.8 suicides per year) occurred during the postintervention period (92.4 study years) - a 91% reduction in suicides. A meta-analysis of all studies assessing jumping means restriction interventions (delivered in isolation or in combination with other interventions) showed a directionality of effect in favour of the interventions, as evidenced by a reduction in the number of suicides at intervention sites (12 studies; incidence rate ratio (IRR) = 0.09, 95% confidence interval (CI) 0.03 to 0.27; P < 0.001; I² = 88.40%). Similar findings were demonstrated for studies assessing jumping means restriction interventions delivered in isolation (9 studies; IRR = 0.05, 95% CI 0.01 to 0.16; P < 0.001; I² = 73.67%), studies assessing jumping means restriction interventions delivered in combination with other interventions (3 studies; IRR = 0.54, 95% CI 0.31 to 0.93; P = 0.03; I² = 40.8%), studies assessing the effectiveness of physical barriers (7 studies; IRR = 0.07, 95% CI 0.02 to 0.24; P < 0.001; I² = 84.07%), and studies assessing the effectiveness of safety nets (2 studies; IRR = 0.09, 95% CI 0.01 to 1.30; P = 0.07; I² = 29.3%). Data on suicide attempts were limited and none of the studies used self-harm as an outcome. There was considerable heterogeneity between studies for the primary outcome (suicide) in the majority of the analyses except those relating to jumping means restriction delivered in combination with other interventions, and safety nets. Nevertheless, every study included in the forest plots showed the same directional effects in favour of jumping means restriction. Due to methodological limitations of the included studies, we rated the quality of the evidence from these studies as low. A cost-effectiveness analysis suggested that the construction of a physical barrier on a bridge would be a highly cost-effective project in the long term as a result of overall reduced suicide mortality.

AUTHORS' CONCLUSIONS

The findings from this review suggest that jumping means restriction interventions are capable of reducing the frequency of suicides by jumping. However, due to methodological limitations of included studies, this finding is based on low-quality evidence. Therefore, further well-designed high-quality studies are required to further evaluate the effectiveness of these interventions, as well as other measures at jumping sites. In addition, further research is required to investigate the potential for suicide method substitution and displacement effects in populations exposed to interventions to prevent suicide by jumping.

Medically Assisted Dying and Suicide: How Are They Different, and How Are They Similar?

The practice of medically assisted dying has long been contentious, and the question of what to call it has become increasingly contentious as well. Particularly among U.S. proponents of legalizing the practice, there has been a growing push away from calling it "physician-assisted suicide," with assertions that medically assisted dying is fundamentally different from suicide. Digging deeper into this claim about difference leads to an examination of the difference between two kinds of suffering-suffering from physical conditions and suffering from psychological conditions-and therefore leads also toward an examination of whether requests for medical assistance in dying by those suffering from psychological conditions and those suffering from physical conditions should be painted with the same brush. In this article, I aim both to illuminate some of the considerations that ought to be included in discussions related to medically assisted dying and to shed light on what the indirect effects of such discussions can be. I consider some of the reasons commonly given for holding that suicide and medically assisted dying differ fundamentally and then whether the conclusion that medically assisted dying should not be called "suicide" follows from the premises. I ask what else might justify the conclusion that the two acts ought to be called by different names, and I examine possible justifications for accepting this premise, as well as what justifications might exist for emphasizing how the acts are alike. Finally, I argue that we should be cautious before concluding that medically assisted dying should not be called "suicide." We need more evidence either that the two acts are fundamentally different or that emphasizing differences between them is not likely to do more harm than good.

Suicide prevention and patient safety

Suicide is a major national and global problem. John Tingle discusses several recent reports on suicide prevention and addresses some litigation and patient safety issues.

Clinician testimony in suicide litigation: A cause to be uneasy

This is an illustrative article rather than a research study. We offer opinions and recommendations about what we view as unfortunate clinician testimony in suicide-related malpractice cases, testimony that - inadvertently or not - supports or encourages inadequate care of suicidal patients. The principles apply to both psychiatrists and non-psychiatrists, although the former appear more often in our work. We particularly consider the roles and testimony, in court or at deposition, of psychiatrists, whether as defendants, expert witnesses, or fact witnesses. We cite examples of what we view as poor, disingenuous, dishonest and even dangerous testimony that we believe moves the profession toward unsafe patient care. The examples illustrate what we (and sometimes others) describe as normalization of deviance, pre-suit puffery, self-serving defendant testimony, expert pride supplanting testimonial responsibility, expert arrogance, expert parroting of attorney suggestions, witness ignorance and avoiding facts, unconscious expert bias, inexperience thwarting justice, misleading use of terms such as "predictability," and expert witnesses who lack the direct-care experience that jurisdictions often require in order to opine about defendant clinicians' day-to-day patient care. The examples often reveal concerns beyond the category chosen, and should not be expected to convey all of the facts of a particular case.

Machine learning in suicide science: Applications and ethics

For decades, our ability to predict suicide has remained at near-chance levels. Machine learning has recently emerged as a promising tool for advancing suicide science, particularly in the domain of suicide prediction. The present review provides an introduction to machine learning and its potential application to open questions in suicide research. Although only a few studies have implemented machine learning for suicide prediction, results to date indicate considerable improvement in accuracy and positive predictive value. Potential barriers to algorithm integration into clinical practice are discussed, as well as attendant ethical issues. Overall, machine learning approaches hold promise for accurate, scalable, and effective suicide risk detection; however, many critical questions and issues remain unexplored.

Custodial suicide and class action remedies: Current obstacles and future directions

Custodial suicide is a foundational concern for correctional systems. The incarcerated population is at an increased risk for suicide as compared with people living in the community. Sufficient suicide prevention is a critical component of a constitutionally adequate system of correctional mental health care. The remedial phases of class action litigations have animated improvement in suicide prevention in many correctional systems across the United States. In the current climate, many legal obstacles make it more difficult for plaintiffs to prevail in such cases, but it is expected that advocates will find novel approaches in response to these legal hurdles, such as greater reliance on state law remedies, and will seek to expand the scope of potential actions in emerging areas such as immigration detention. Defendants and courts will, in turn, need to respond to these changes. This article explores the history of relevant litigations, and the legal obstacles currently faced by plaintiffs, as well as future directions the authors consider will likely be taken. Practical issues such as appropriate measurement of improvement in the area of suicide prevention are also explored.

Suicide Crisis Syndrome: A review of supporting evidence for a new suicide-specific diagnosis

Suicide is a major public health problem, and suicide rates are still on the rise. Current strategies for identifying individuals at risk for suicide, such as the use of a patient's self-reported suicidal ideation or evidence of past suicide attempts, have not been sufficient in reducing suicide rates. Recently, research groups have been focused on determining the acute mental state preceding a suicide attempt. The development of an acute suicidal diagnosis, the Suicide Crisis Syndrome (SCS), is aimed at capturing this state to better treat individuals. The SCS has five main evidence-based components-entrapment, affective disturbance, loss of cognitive control, hyperarousal, and social withdrawal. The SCS may provide clinicians with the ability to identify individuals who are experiencing an acute pre-suicidal mental state, regardless of their self-reported suicidal ideation. Future research leading to the incorporation of this diagnosis into clinical practice could improve the quality of care and reduce the personal, societal, and legal burden of suicide.

Documenting suicide risk assessments and proportionate clinical actions to improve patient safety and mitigate legal risk

Few clinical practices are as important for simultaneously augmenting patient safety and mitigating legal risk as the judicious evaluation and stratification of a patient's risk for suicide, proportionate clinical actions based thereon taken by the healthcare provider, and contemporaneous documentation of the foregoing. In this article, we draw from our combined decades of multidisciplinary experience as a clinical psychologist, forensic psychiatrist, medical malpractice attorney, and clinical psychology trainee to discuss the documentation of suicide risk assessment and management as a conduit to patient safety and legal risk mitigation. We additionally highlight documentation as a core clinical competency across disciplines and note areas of improvement, such as increased training, to bolster documentation practices.

"Hey, let me hold your guns for a while": A qualitative study of messaging for firearm suicide prevention

A recommended component of suicide prevention is encouraging at-risk individuals to voluntarily and temporarily reduce access to firearms and other lethal methods. Yet delivering counseling on the topic can be difficult, given the political sensitivity of firearm discussions. To support such counseling, we sought to identify recommended framing and content of messages about reducing firearm access for suicide prevention. Through qualitative interviews with firearm owners and enthusiasts, we identified key points for use in framing (identity as a gun owner, trust, voluntary and temporary storage, and context and motivation) and specific content (preference for "firearm" over "gun," and legal issues such as background checks for transfers). These findings build on prior work and should enhance efforts to develop and deliver effective, acceptable counseling and-ultimately-prevent firearm suicide.

Misconduct, Self-inflicted Injury, and Suicide in Workers Compensation: A Review of the Australian Legal Framework

The no-fault principle is one of the pillars of workers' compensation schemes operating in the States, Territories and the Commonwealth in Australia. This article examines the strength of this principle having regard to provisions common to all jurisdictions which disentitle workers where there is evidence of serious and wilful misconduct or self-inflicted injury. It examines the legislative framework of these provisions in detail noting some differences in approach and effect. The article also traces the origins of these provisions and how they have been applied since enacted. We conclude that the no-fault principle remains robust and intact in Australian workers' compensation schemes.

From condemnation to understanding: Views on suicidal behavior in Ghana in transition

The cultural context in which suicide occurs has been emphasized as critical in understanding the act and informing prevention. Yet the penchant of psychiatrizing suicidality in mainstream suicidology relegates cultural issues to the background. Through the lenses of critical cultural suicidology, the authors have re-emphasized the importance of culture by reviewing the two major meanings of suicide as observed in our 8-year study in Ghana: moral transgression and life crisis. They have also showed the usefulness of the life crisis perspective of suicidality in reducing stigma and sustaining advocacy in decriminalizing attempted suicide in the country.

Preventing Prison Suicide With Life-Trajectory-Based Screening

We describe the application of a life-trajectory model of suicide to the prison setting and its implication for suicide risk detection. A model has been developed that describes two distinct trajectories culminating in suicide: one with large amounts of adversity early in life with a young age of suicide and another with chronic, gradually accumulating adversity with a later age of suicide. Support for applying the life-trajectory model to the prison population is found in prison-centric models of suicidal behavior and clinical profiles of individuals at high risk of suicide in prisons. We also describe how the life-trajectory model applies to two recent high-profile suicides within the Canadian prison system. Finally, we propose a screening tool based on the life-trajectory model to quantify an individual's adversity burden at intake and subsequently throughout incarceration. We describe how this proposed tool may improve detection of individuals with increased risk of suicide and describe the steps necessary for the development of this tool.

[Homicide-suicide, double suicide or homicide followed by suicide 2 case reports]

Cases in which several persons who died from an unnatural cause are found together are often difficult. It is necessary to exclude homicide committed by another person and to clarify whether the deaths are the result of a homicide-suicide or a joint suicide of persons wishing to die. Two cases in which couples with gunshot wounds to the head had been found lifeless in their homes are presented. In both cases, the deceased were of advanced ages and suffered from severe pre-existing diseases. Due to the circumstances at the scene, the results of the investigations and the autopsies as well as the suicide notes found, a double suicide was assumed in both cases. The husbands killed themselves after shooting their wives. Based on the presented cases the so-called double suicide and the need for a thorough investigation of the death scene with the problem of differentiating it from homicide-suicide and double homicide are discussed.

Deaths in Hamburg prisons 1996-2012 - Recommendations on suicide prevention in prison custody

130 cases of prisoner deaths in Hamburg were examined in a doctoral thesis providing the basis for this study (P e t ers en 2016). Compared with previous assessments, prisoners live longer and are slightly more likely to die of natural causes, the most common cause of death being heart attack. Also, medical care in prisons has significantly improved - some prisoners in fact receive better treatment while incarcerated as compared to outside of prison. The suicide risk, however, remains 8 times as high for inmates compared to the general population. 55 % of these suicides take place within the first 30 days of pre-trial detention. Most of the suicides in Hamburg prisons (26 %) occur on Sundays. In previous studies this number was lower at 15 % (Granzow 1996) and nationwide it was at 20 % (Bennef eld-Kersten 2012). The paper also provides 18 recommendations to prevent future suicides of prisoners. Overall, the rate of prison suicides is slightly decreasing. Prisoners today live longer and mostly die of lifestyle diseases, particularly heart attacks. However, they are still significantly more likely to take their own life than individuals living in freedom.

Suicide by stabbing while driving a car

Complex suicides represent only a small number of all suicides. The case of a 27-year-old man who drove his car against a tree is presented. The emergency physician diagnosed a stab to the thorax. A kitchen knife was found on the rear seats of the vehicle. Autopsy revealed death by exsanguination due to perforation of the left cardiac ventricle. Blunt force injuries caused by the collision were also found.

An ecological analysis of prison overcrowding and suicide rates in England and Wales, 2000-2014

Prisoners are at a greatly increased risk of suicides compared to the general population. Differences in suicide risk can be partly explained by individual risk factors, but the contribution of prison characteristics remains unclear. Overcrowded prisons have higher suicide rates, but this may be related to prison function, security level, population size and turnover. The aim of the current study was to investigate the contribution of each of these prison characteristics to suicide rates, using data from the Ministry of Justice for adult prisons in England and Wales from 2000 to 2014. Negative binomial regression analysis showed that larger population size, higher turnover, higher security and public management were associated with higher suicide rates. When controlling for these factors, overcrowding was not found to be related to suicide rates. Questions remain about the causal mechanisms underlying variation in prison suicides and the impact of the lived experience of overcrowding. Further research is needed to examine the relative contribution of prison and prisoner characteristics to suicides.

Lethal hypothermia after firing a suicidal shot to the head in a car

In suicide cases involving an automobile, the car is mostly used as a tool/instrument for the suicide (intoxication by exhaust fumes, crash against solid objects such as a pylon). However, a car is uncommonly also used only as the location for a suicide. In the present case, a 70-year-old man had been found dead on the passenger seat of his car. According to witnesses, the car had not been parked there at the same time of the previous day. During that period, the weather had been dry, with temperatures ranging from -1⁰ C at night to +5⁰ C during the day. The man had shot himself with a small-caliber revolver (so-called bulldog-revolver) almost horizontally in the left temple (transtemporal shot through the frontal lobes). Obviously, the suicide had retained the capability to act at least for a short time, as the revolver was found under his left bottom. As morphological signs of prolonged agony some findings of hypothermia were observed (e. g. Wischnewski spots of the stomach).

Unusual planned complex suicide committed with a muzzle-loading pistol in combination with subsequent hanging

In Germany, suicides by firearms are not very common in contrast to deaths by hanging and intoxications. The use of historical muzzle-loading firearms in the context of suicides is a rarity. Contact shots from muzzle loaders cause an unusual wound morphology with extensive soot soiling. We report the case of a 59-year-old man, who committed a planned complex suicide by shooting into his mouth with a replica percussion gun in combination with hanging. The gunshot injury showed strong explosive effects in the oral cavity with fractures of the facial bones and the skull associated with cerebral evisceration (so-called Krönlein shot). Due to the special constellation of the case with hanging immediately after the shot, external bleeding from the head injuries was only moderate. Therefore, the head injuries could be assessed and partially reconstructed already at the scene.

Interrupted (self -)medication with pancuronium(bromide) and fatal outcome

Pancuronium(bromide) is used because of its relaxing effect on striated muscles and usually requires artificial respiration. A 52-year-old woman suffered from long-standing "generalized dystonia", which had become resistant to conventional therapy. Therefore, an anesthetist established a permanent medication scheme with pancuronium using a PCA pump. This pump had been controlled by the patient herself ensuring an acceptable quality of life with broad personal autonomy. Finally, the woman was found dead in her flat by a member of a home nursing service. The infusion hose showed a fixed knot and further blocking by a clamp. The autopsy findings were non-specific, except for the presence of opioid tablets in the colon. Toxicological analyses showed 72ng/ml pancuronium and 21 ng/ml oxycodone (therapeutic) in the femoral venous blood. The range of published pancuronium levels varies from approx. 80 to 2,000 ng/ml. Thus it had to be assumed that the pancuronium level was too low (72 ng/ml) so that symptoms of dystonia recurred. Based on extensive literature research, the described case can be qualified as unique. The therapy concept had been innovative, sufficient and effective for more than 10 years. It allowed the patient to enjoy a maximum of autonomy. Ultimately, death was due to the blocked pancuronium infusion. The relatively low pancuronium level had provoked the dystonia to return with generalized spasms also involving the respiratory muscles resulting in respiratory arrest. During the police investigations, two previous suicide attempts came to light.

On manual laterality (handedness) in humans and its forensic significance - a literature review

Manual laterality (handedness) in humans has some significance for forensic practice where it is primarily employed in the form of handedness preference, based on a simplified three-stage classification (right-handed, left-handed and ambidextrous). In cases of homicide or suicide, the pattern of injuries, particularly cutting or stab injuries and gunshot wounds, may provide clues as to the perpetrator's handedness. In injuries inflicted by another person, the pattern of findings can in isolated cases allow to draw conclusions as to the handedness of the perpetrator. In self-inflicted injuries and suicide, the dominant hand is usually used either alone or as the lead hand. If it is found that fatal injuries were inflicted by the non-dominant hand, this gives rise to doubt that the manner of death is suicide. Evidence of handedness is of little value in distinguishing between suicide and homicide. Due to new developments in dentistry, imaging procedures and especially genetics, the utility of handedness in the identification of unknown persons or cadavers has significantly diminished. In living subjects, useful evidence of handedness can be obtained by observing the performance of specific gestures or activities. The subject should be asked to perform tasks involving one and two hands in a specific sequence. Standardised measurements of the morphology of the shoulders and upper extremities are able to make a statistical distinction between right and left. Since the accuracy of this process is, however, only,around 75 %, morphological determination of handedness should not be used in living subjects, but should be restricted to the identification of unknown cadavers or other post-mortem examinations.

Necessity of including medico-legal autopsy data in epidemiological surveys of individuals with major trauma

BACKGROUND

It is rare that epidemiological surveys of patients with major trauma include both those admitted to the emergency department and those sent for medico-legal autopsy. The main aim of the present population-based study of major trauma was to examine the importance of medico-legal autopsy data.

METHODS

A new injury severity score (NISS)>15 or lethal outcome was used as criteria for major trauma and to identify patients at the emergency, anaesthesiology and forensic departments and/or being within the jurisdiction of the Malmö police authority and subjected to a medico-legal autopsy between 2011 and 2013. According to Swedish legislation all trauma related deaths should be reported to the police who refer these cases for medico-legal autopsy.

RESULTS

Among the 174 individuals included, 92 (53%) died and 81 (47%) underwent medico-legal autopsy. One hundred twenty-six patients were primarily admitted to hospital and 48 died before admission to hospital and were sent directly for medico-legal autopsy. Forty-four in-hospital deaths occurred, of whom 33 (75%) were sent to medico-legal autopsy. In those sent directly to the department of forensic medicine the proportion of accidents was lower (p<0.001), self-inflicted injuries higher (p<0.001) and gunshot wounds higher (p=0.002) in comparison with those sent to hospital. The most prevalent drugs detected by forensic toxicology screening in the 81 fatalities were ethanol (20%), sedatives (16%), anti-depressives (15%) and illicit narcotics (9%). Forty-four cases (54%) were positive for at least one drug, and twenty-eight cases (35%) were positive for two or more drugs. Factors associated with a lower rate of medico-legal autopsies among trauma-related deaths at hospital were high age (p<0.001), lower NISS (p<0.001), a longer duration between trauma and death (p<0.001), falls (p=0.030) and trauma-related infections (p<0.001).

CONCLUSION

This population based study covering clinical and forensic data shows that more than half of the individuals sustaining major trauma died. An additional 25% of the in-hospital fatalities should have undergone medico-legal autopsy according to legislation, but did not. The high proportion of positive toxicological findings among fatalities examined at medico-legal autopsy implies that toxicology screening should be routine in major trauma patients, in order to improve treatment and prevention.

[Suicide in childhood or accidental hanging? A case report]

Suicides of children, adolescents and young adults are a rare manner of death. Hanging is the dominant suicide method in all age groups. Risk factors for suicide at a young age are mental diseases, use of illicit drugs, antisocial behaviour and problems within the family. A 10-year-old boy was found to have hanged himself with a scarf at the handrail of a staircase. He had had school problems and was often sent home earlier as he tended to disturb classes. In the week prior to his death the headmaster of his school had told him that he should better attend another type of school. The deceased's elder brother had recorded a video with his mobile phone some years before showing his sister in a simulated hanging situation. Apart from the macroscopic and microscopic findings of the reported case, the frequency and special characteristics of suicides in childhood and adolescence are discussed.

[Wrong statement of manner of death after insufficient post-mortem examination]

When death certificates already completed are submitted during forensic post-mortem examinations or autopsies, blatant errors are often found, especially with regard to the classification of the manner of death. This is partly attributable to insufficient knowledge of the classification criteria, but also to the fact that the post-mortem examination was not properly performed and even clear signs of unnatural death (e.g. a strangulation mark or sharp force injuries) are overlooked. To avoid such misinterpretations, a thorough reformation of the post-mortem examination system and a regular continuing specialized training of the physicians performing post-mortems seem necessary.

[Alleged suicide by insulin]

A 26-year-old man, who was on probation, was found dead in his home by his mother. Insulin vials and 2 insulin pens, which the man's stepfather (an insulin-dependent diabetic) had been missing for over a week, were found next to the deceased. The circumstances suggested suicide by an injected insulin overdose. At the time of the autopsy, the corpse showed already marked signs of autolysis. Clinical chemical tests confirmed the injection of insulin, but indicated hyperglycemia at the time of death. Toxicological analyses revealed that the man had consumed amphetamine, cannabinoids, and tramadol in the recent past. Histological examination finally revealed extensive bronchopneumonia as the cause of death. The most plausible explanation for the results of the autopsy and the additional examinations was an injection of insulin as a failed attempt of self-treatment. It is conceivable that the man had discovered by a rapid test that he was a diabetic, but had decided not to go to a doctor to avoid disclosure of parole violation due to continued drug abuse. He may have misinterpreted the symptoms caused by his worsening bronchitis and the developing bronchopneumonia as symptoms of a diabetic metabolic status and may have felt compelled to treat himself with insulin.

[Intentional poisoning of two wives by their husband?]

The authors report on the death of two women who were married to the same man one after the other. Exhumation and toxicological investigation of the first wife, who had died 7 years before, did not produce any conclusive evidence of homicide. With regard to the circumstances of death of the second wife the husband made different statements. According to the result of the chemical and toxicological investigations death was caused by acute intoxication with the beta-blocker metoprolol. The man was found guilty of killing on request (which is a criminal offence in Germany) by administering the beta-blocker metoprolol through a transnasal gastric tube.

[Cause and manner of death in the autopsy material of the Institute of Forensic Medicine, Justus Liebig University Giessen, from 2002-2006]

A retrospective analysis of the autopsy material of the Institute of Forensic Medicine, Justus Liebig University Giessen, in the years 2002 to 2006 showed that the Giessen material is similar to that of comparable studies but contains a relatively large share of lethal intoxications and cases with a concrete suspicion of poisoning in which the cause of death was not definitely clarified by further investigations. On the basis of our own results it is demonstrated that additional chemical, toxicological and histological examinations are helpful to determine initially unclear causes of death. In view of the already very low autopsy rates in Germany it is strange that more detailed diagnostic measures are often omitted.

Firearms regulation, violence and the mentally ill: a contemporary Antipodean appraisal

As recent cases of mass murder at Utoya Island in Norway, and in the United States (US) at Virginia Tech, Virginia; Tucson, Arizona; Aurora, Colorado; and Newtown, Connecticut all illustrate, acts of extreme violence involving high powered weapons and committed by persons with a presumed or confirmed mental illness tend to arouse intense public and political debates about the efficacy of firearm regulation and control. Following these tragedies, in the US at least, various law reform measures have been proposed and in some cases implemented designed principally to make it more difficult for mentally ill persons to gain access to firearms. In this article it is contended that measures like these are at best tinkering with the margins of gun control and also have the tendency to reinforce the stigma and discrimination experienced by persons with a mental illness, while perpetuating stereotypes of them as dangerous to themselves and others. Despite these limitations, and while firearm regulation policies and practices vary widely across the globe, most nations still seek in some way to limit access to guns by persons with a mental illness. This article explores in more detail how such policies and practices have been applied in the Australian State of New South Wales and the lessons to be learned elsewhere from this experience.

Suicide, assisted suicide and euthanasia: International perspectives

Suicide, assisted suicide and euthanasia are elusive and controversial issues worldwide. To discuss such issues from only one perspective may be limiting. Therefore, this paper was written by authors from various regions, each of whom has been asked to reflect on the issues. The countries/cultures are: Australia, China, Cuba, Ireland, India, Japan, Russia, South Africa, The Netherlands, North America (Turtle Island) and United States. Historically and today, suicide is viewed differently. Assisted suicide and euthanasia are equally seen from multifarious perspectives. Highlighting development in the Netherlands, Australia's Northern Territory and Japan (ie. the famous Yamanouchi Case), the review shows growing re-examination of the right to die. There appear, however, to be no uniform legal and ethical positions. Further debate and discussion globally is needed to avoid myopic perspectives.

[Risk and suicide in open door institutions. Liability and forensic issues]

Suicide is a complex issue and a source of discussion between different disciplines. Suicide assessment and management research had received a huge attention in the field. Argentina has a legal framework focused on protecting human rights. Malpractice and liability discussion is offered in cases of suicide in psychiatric patients recently admitted to an inpatient setting. Imminent and certain risk of damage is the legal requirement for involuntary psychiatric admission in terms of Mental Health Law in Argentina.

[Unusual findings in carbon monoxide-related deaths]

The authors present three cases of carbon monoxide poisoning (two suicides and one accident) from the autopsy material of the Institute of Legal Medicine at Basel, which are unusual with regard to the circumstances at the scene of death, the method of suicide and the post-mortem findings: Suicide of a 27-year-old male by burning charcoal in the bathroom, documentation of the suicide and previous attempted suicides on a tablet PC. Suicide of a 27-year-old male by carbon monoxide chemically, produced by dehydration of formic acid with sulphuric acid and inhalation of the gas through a breathing mask. Accidental carbon monoxide poisoning of a 34-year-old male by car exhaust fumes in an open garage. Difficult establishment of the diagnosis in the post-mortem examination due to unspecific colour of livores and varnished fingernails.

Suicide: rationality and responsibility for life

OBJECTIVES

Death by suicide is widely held as an undesirable outcome. Most Western countries place emphasis on patient autonomy, a concept of controversy in relation to suicide. This paper explores the tensions between patients' rights and many societies' overarching desire to prevent suicide, while clarifying the relations between mental disorders, mental capacity, and rational suicide.

METHODS

A literature search was conducted using search terms of suicide and ethics in the PubMed and LexisNexis Academic databases. Article titles and abstracts were reviewed and deemed relevant if the paper addressed topics of rational suicide, patient autonomy or rights, or responsibility for life. Further articles were found from reference lists and by suggestion from preliminary reviewers of this paper.

RESULTS

Suicidal behaviour in a person cannot be reliably predicted, yet various associations and organizations have developed standards of care for managing patients exhibiting suicidal behaviour. The responsibility for preventing suicide tends to be placed on the treating clinician. In cases where a person is capable of making treatment decisions--uninfluenced by any mental disorder--there is growing interest in the concept of rational suicide.

CONCLUSIONS

There is much debate about whether suicide can ever be rational. Designating suicide as an undesirable event that should never occur raises the debate of who is responsible for one's life and runs the risk of erroneously attributing blame for suicide. While upholding patient rights of autonomy in psychiatric care is laudable, cases of suicidality warrant a delicate consideration of clinical judgment, duty of care, and legal obligations.

[Analysis of human tissue samples for volatile fire accelerants]

In police investigations of fires, the cause of a fire and the fire debris analysis regarding traces of fire accelerants are important aspects for forensic scientists. Established analytical procedures were recently applied to the remains of fire victims. When examining lung tissue samples, vapors inhaled from volatile ignitable liquids could be identified and differentiated from products of pyrolysis caused by the fire. In addition to the medico-legal results this evidence allowed to draw conclusions as to whether the fire victim was still alive when the fire started.

End-of-life mental health assessments for older aged, medically ill persons with expressed desire to die

In recent years, assisted suicide has been legalized in four states for those who are terminally ill and wish to end their lives with the assistance of lethal doses of medications prescribed by a physician. The ethics-related and legal questions raised by end-of-life suicide and decisional capacity to refuse treatment assessments are complex. In treating patients with end-stage medical conditions or disorders that severely affect the future quality of their lives, clinicians tend to engage in suicide prevention at all costs. Overriding the patient's expressed desire to die conflicts with another value, however, that of the individual's right to autonomy. We provide a framework for understanding these difficult decisions, by providing a review of the epidemiology of suicide in later life; reviewing findings from a unique dataset of suicides among the elderly obtained from the Los Angeles County Coroner's Office, as well as data from states with legalized assisted suicide; presenting a discussion of the two frameworks of suicidal ideation as a pathological versus an existential reaction; and giving a case example that highlights the dilemmas faced by clinicians addressing decisional capacity to refuse treatment in an elderly, medically ill patient who has expressed the wish to die.

Single cells, segregated housing, and suicide in the New Jersey Department of Corrections

Single-cell and segregated housing are established risk factors for suicide in prison. The importance of these factors together may represent a disproportionate risk and are both modifiable. We tallied the housing locations and single- versus double-cell status of the 26 inmates who committed suicide in the New Jersey Department of Corrections (NJDOC) from 2005 through 2011, and compared the suicide rates in these housing arrangements. All single-cell housing in the NJDOC (whether segregated or general population) represented a higher risk of suicide than double-cell housing in the general population. Single-cell detention was the riskiest housing in the NJDOC, with a suicide rate that was more than 400 times the rate of suicide in double-cell general population housing and 23 times the rate of suicide in the prison system overall. The odds ratios of suicide in single-cell detention represent the highest reported in the literature in terms of risk factors for suicide in prisoners. Apprised of this risk, the NJDOC, assisted by its mental health vendor, University Correctional Health Care (UCHC, of Rutgers University, formerly the University of Medicine and Dentistry of New Jersey), adopted in 2012 a practice of default double-celling of inmates placed in detention.

[Efficiency of inspections of the corpse before cremation performed in the area of the Halle University Medical Centre]

From 1993 to 2007, the Institute of Forensic Medicine in Halle conducted 882 post-mortems before cremation. These records were now used for a systematic analysis of these cases to assess the efficiency of so-called second inspections of the corpse carried out in the area covered by the Halle University Hospital. In the period under review, considerable fluctuations were found from year to year, but these are mainly attributable to changes in the Saxony-Anhalt burial law introduced in 2002. Our 882 post-mortems were based on 84,677 corpse inspections before cremation; thus, an autopsy was performed in about 1% of all cases. Males were significantly overrepresented, younger age groups were dominant and there was a relatively high percentage where the first inspection of the corpse could not determine the manner of death or had to declare death by an unnatural cause. With regard to the manner and cause of death, the results of the first inspection and the post-mortem differed significantly. In 17.6% of our 882 cases, only the post-mortem revealed that death had been due to an unnatural cause. Despite the presence of sometimes strong clues to an unnatural cause, 156 of these cases were classified as natural deaths (56.4%) or the manner of death was stated as undetermined (43.6%). For more than two thirds of these 156 cases we were able to inspect the records kept by the Departments of Public Prosecution. 105 of these at first overlooked cases of unnatural deaths turned out to be deaths by accident. The other cases included 11 suicides, and 36 deaths related to medical treatment. In the remaining four cases, the autopsy results strongly suggested homicide, but only in one of these four cases subsequent police investigations were able to identify the perpetrator. This outcome demonstrates that the rule of inspecting the corpse a second time before cremation is clearly indispensable, even in its currently rather limited form.

The right to life in a suicidal state

This paper considers when the State must take positive steps to protect the right to life of a suicidal patient. Using recent developments across the Council of Europe which challenge the traditional 'ugly Samaritan' approach of many common law systems, it contends that whenever and wherever public authorities know or ought to know of a real and immediate risk to the life of an identifiable person, they must take reasonable precautions to minimise it. Even J. S. Mill's approach to liberty, it is suggested, would tolerate this limited degree of State interference. However, notions of autonomy and dignity, the unpredictability of human behaviour, and the need to avoid unduly burdening the State must influence what it means to act reasonably.

The interface of the civil and criminal law of suicide at common law (1194-1845)

Nowadays, suicide is considered essentially a private act, although what constitutes suicide for epidemiological and even clinical purposes in not wholly resolved. Historically, however, at common law, the act of self-killing was a felony with significant religious and legal consequences that impacted upon the deceased person as well as upon his or her whole family. This article identifies the influence of Christian theology, legal theory, and social and medical developments upon attitudes to the felony of self-murder and its definition. It focuses upon the start of more psychologically informed attitudes manifested in landmark court judgments involving exclusion clauses in English mid-nineteenth century insurance contracts. The article illustrates that the law in respect of socially controversial matters does not necessarily develops in a linear progression, nor does it accurately reflect public sentiments. More specifically, the article describes an ongoing definitional conundrum with suicide--whether it should be designated as committed by persons of significantly impaired mental state. The authors observe that in spite of reform to the criminal law of suicide, the civil law relating to suicide has continued to be characterised by ambivalence, ambiguity and significant vestiges of counter-therapeutic moralising.

Assisted suicide through the prism of the right to life

Part of the reason for the ongoing confusion regarding the status of assisted suicide is the cluttered moral and legal matrix that is normally invoked to evaluate the practice. It results in a calculus that is impossible to coherently unravel, allowing commentators to tenably assert any position. The authors attempt to inject clarity into the debate by focusing on the issue through the lens of the most important interest at stake: the right to life. It is arguable that while there are well-established exceptions to the right to life, they only apply where the right to life is itself at stake (such as self-defence). There is no sound argument for suggesting that the circumstances underpinning suicide constitute another exception to the right to life. Thus, suicide and assisted suicide are unjustifiable. An analysis of the empirical data in jurisdictions where assisted suicide has been legalised suggests that legalisation leads to an increase in assisted suicides. The adverse indirect consequences of the often ostensibly compassionate act of assisted suicide outweigh any supposed benefits from the practice. It follows that assisted suicide should lead to criminal sanctions. At the same time, it is important to acknowledge that, paradoxically, the right to life arguments against assisted suicide mandate greater community measures to eliminate or reduce the causes of suicide.