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

around the world. This likely stems from the easy accessibility
of victims to a myriad range of ligatures and locations to sus-
pend themselves and the relatively rapid lethality of this
method of suicide. From a death investigation standpoint,
hanging fatalities are rarely problematic. Occasionally, a
dilemma arises in identifying the manner of death, most com-
monly in trying to distinguish a suicidal hanging from an
accidental event. Extremely rare are cases of hanging due to
homicidal violence (1–6). Typically, hanging is associated with
a lesser degree of external and internal trauma compared with
the other types of neck compression, specifically ligature and
manual strangulation (7,8).
The data in the literature regarding frequency of
hanging-related neck injuries are controversial. The reported
incidence of occurrence of laryngeal and hyoid fractures varies
from 0% to 76.8% (9–11). A number of factors are recog-
nized which influence the incidence of various hanging-related
neck injuries. Taking these factors into consideration while
evaluating postmortem findings further assists their accurate
interpretation.
The first goal of this study was to review the population
demographics and the incidence of unusual and special circum-
stances in hanging fatalities which can raise concerns for investi-
gators. The second objective was to determine the incidences of
different hanging-related neck injuries and correlate them with
major recognized contributing factors.
1
Department of Pathology & Laboratory Medicine, London Health
Sciences Centre, London, ON, N6A 5A5, Canada.
2
Department of Psychology, King’s College, Western University, London,
ON, N6A 2M3, Canada.
Received 8 Sept. 2015; and in revised form 23 Jan. 2016; accepted 30
Jan. 2016.
Materials and Methods
This study was based on retrospective analysis of consecutive
cases of hanging deaths that happened in the province of Ontario
during the two-year period from January 1, 1998, to December
31, 1999. This study period was chosen to allow evaluation of a
sufficient number of cases which had a complete postmortem
examination. In current forensic pathology practice in Ontario,
hanging death postmortems tend to be limited to external exami-
nation only if the circumstances indicate definite suicidal intent
(e.g., suicide note, recent or past suicidal ideation, or attempts)
in an individual, usually male, in a secure environment. Post-
mortem examinations were performed in different institutions,
including specialized forensic pathology units, and teaching and
community hospitals.
Data were collected from the files in the archives of the Office
of the Chief Coroner for Ontario. These included the coroner’s
investigation statements, police reports of incidents with witness
statements, and reports of postmortem examination. Relevant
epidemiological data of the deceased individual (i.e., sex, age,
weight, height, and body habitus) were recorded using standard-
ized datasheets. The latter also included information on the man-
ner of death, suicidal risk factors (e.g., past history of mental
illness, suicide threats, prior attempts, note), and resuscitation/
survival details. Unusual circumstances (e.g., restraints, com-
bined suicide) were recorded. As well, collected data included
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
related to risk of suicide. Only cases which had a full post-
mortem examination were evaluated to determine the frequency
and distribution of hanging-related injuries.
All postmortem findings were classified as either hanging
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
cervical spine) and neck soft tissue injuries away from the site
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-
arms).
When stratifying incidents by the type of suspension, the ter-
minology of complete and incomplete suspension was applied.
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).
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.
The data were entered in standardized datasheets and further
analyzed using IBM SPSS Statistics 20 (Statistical Package for
the Social Sciences) for Windows.
Results
A total of 761 cases of hanging were registered in Ontario for
the period from January 1, 1998, to December 31, 1999 (374
cases in 1998 and 387 cases in 1999). Six cases where post-
mortem reports were not available were excluded from the study.
From the remaining 755 cases, 737 (97.6%) were ruled as sui-
cides in the course of coroners’ investigations. Nine cases
(1.2%) were accidents, and two cases (0.3%) were homicides.
For seven cases (0.9%), the manner of death remained undeter-
mined. For five of these cases, the uncertainty was whether
hanging was suicidal or accidental. Among them was a case of
possible autoerotic asphyxiation. In two cases, the manner of
death was either suicide vs. homicide in one and accident vs.
homicide in the other. Complete autopsies were performed in
632 cases (83.7%). Sixty-eight cases (9%) were limited to exter-
nal examination only. In 55 cases (7.3%), no postmortem exami-
nation was performed.
Population Demographics
Age and Sex—The mean age of the deceased individuals was
40.6 years (the youngest individual was 2 years of age and the
oldest was 94). Case distribution by age and sex is demonstrated
in Fig. 1. There was a male predominance: 624 (82.6%) dece-
dents were males and 131 (17.4%) were females. Similar distri-
butions were observed in cases which had complete autopsies,
with the mean age being 39.8 years (males—39.8; females—
39.5) and a male predominance of 81.3%.
Past Psychiatric History and Suicidal Intent—Of 613 suicidal
hangings where prior psychiatric history was described in the
affirmative or not, 579 individuals (78.6%) had a history of
some type of mental illness. This included mood disorders, per-
sonality/behavior disorders, and other psychiatric conditions,
including substance-related and addictive disorders. History of
depression was documented in 442 cases (60%). A history of
substance abuse was reported in 200 (27.1%) cases. In 54 cases,
substance abuse was present without any other diagnosed psy-
chiatric disorder. In only 22 cases (3%) was there a definitive
statement of no past psychiatric history.
In approximately half (49.5%) of suicidal hangings, the pres-
ence of a suicide note and/or suicide attempts/threats was
GENDER
male
200 female
150
NUMBER OF CASES
100
50
0
0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 >90
AGE GROUPS
FIG. 1––Case distribution by age and gender.
documented. Suicide notes were found in 151 cases (20.5%) and
preceding threats to kill oneself were recorded in 138 cases
(18.7%). In 267 cases (36.2%), there was a history of prior sui-
cide attempts including 97 cases (13.2%) where attempts were
multiple. In 37 cases (13.9% of cases with a history of attempted
suicides), prior attempts were by hanging. In addition to these
cases, there were 16 cases with evidence of a failed hanging
attempt a short time prior to the fatal hanging. In the majority of
these cases, there was a history of the deceased phoning some-
one to report an unsuccessful first hanging attempt. In two of
the cases, unsuccessful attempts were witnessed. In only three of
the sixteen cases, two separate ligature marks were observed.
Special Circumstances
Near-hanging—Of 44 decedents (5.8%) who exhibited vital
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
examination only. In the majority of longer-term survivors (over
2 days), the cause of death was hypoxic–ischemic encephalopa-
thy due to hanging. The survivors were overall younger (mean
age of 35.3 years) and showed higher female representation
(27%). One of the near-hanging victims sustained a hyoid frac-
ture, and another had cervical spine dislocation.
Pediatric Deaths—Fifty-six deceased (7.4%) were children
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
hanged by their mothers who then hanged themselves. Of the
remaining 54 cases, 46 were suicides, six accidents, and two
undetermined.
All accidental deaths were unwitnessed by adults and involved
children from 4 to 15 years of age. There were an equal number
of boys and girls. These included three cases of younger children
accidentally suspended while playing (by the child’s own cloth-
ing, a window blind cord, and a dance rope), two cases of acci-
dental entanglement with a ligature while doing some purposeful
activity, and one case where hanging was apparently a threaten-
ing activity after the child was disciplined for misbehavior.
The youngest child who committed suicide was an 11-year-
old boy. Overall female incidence was 37% (31.6% in the
 TUGALEVA ET AL.
younger population, 14 years of age or younger and 40.7% in
older children, 15 or older). The proportion of cases (63%), with
a positive psychiatric history (mostly depression, behavioral dis-
orders, personality disorders, and substance abuse), was lower
than in the overall population (78.6%) although less common in
the younger group (52%) than in older children (70.3%). The
frequency (54%) of prior suicidal tendencies (suicide note,
attempt, or threat) was slightly higher than overall population
(49.5%). The frequency of prior attempts (30%) and suicide
notes (19.6%) was similar to the overall population. Although
the frequency of prior attempts was similar in younger and older
children, threats were over three times more common in younger
children. Suicide notes were found only in older group. The
youngest child who left a suicide note was a 15-year-old girl.
Psychiatric Inpatients—Seventeen deceased were inpatients in
a psychiatric ward at the time of the incident. Four of them were
away from the hospital (i.e., leave of absence/weekend pass),
and one patient escaped from a psychiatric facility. Six of the
patients were resuscitated (with a survival time of 2–135 days).
Deaths in Custody—In our study, 21 decedents were in cus-
tody at the time of the incident. All of them were males with a
mean age of 33.6 years. Positive prior psychiatric history was
recorded in all cases including five instances of diagnosed
depression. Near half of the deceased (10 cases) had prior single
or multiple suicide attempts (three by hanging) and documented
suicidal threats (11 instances). Suicide notes were present in a
third of the cases (seven cases). All known suspension types (17
cases) were incomplete. The most common ligatures were bed
sheets (14 cases), which were either intact or torn into strips,
and items of clothing (four cases where shoelaces, overalls, or
socks were used to form a ligature). In only two cases, there
were more “conventional” type ligatures used (i.e., an electric
cord, a cable from exercise equipment). In all but one case, the
manner of death was ruled as suicide. In that one case, the man-
ner was undetermined, that is, either suicide or accident. Regard-
ing the latter manner, in addition to the history of multiple prior
suicide attempts, the deceased had more recently expressed
intent to fake a suicide attempt. Four individuals survived fol-
lowing resuscitation, from 34 h to 26 days.
Hanging Inside a Vehicle—There were two incidents of suici-
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
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-
pended by a dog leash attached to a coat hook.
Double Suicide—Two incidents of double suicide were docu-
mented. The first involved two 13-year-old girls suspended from
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
and son suspended from different rafters by the same rope.
Murder–Suicide—In addition to the above-described two
instances of mother–child hanging deaths, there was a case of a
deceased who took his own life shortly after he stabbed his victim.
Autoerotic Behavior—Five of the deceased were found naked.
Four of the cases were determined to be suicides. The manner of
death for one case remained undetermined because suicide or
accident (potential autoerotic asphyxiation) was possible. All the
. RETROSPECTIVE ANALYSIS OF HANGING DEATHS 3
deceased were males. An additional case of somewhat atypical
autoerotic death was documented in a 19-year-old man who was
found hanging by a dog leash from a set of stairs with no typical
self-release mechanism involved. A pornographic story involving
hanging was found on his computer. The death was concluded
to be accidental. No other cases of autoeroticism were reported
during the studied time period.
Combined Suicide—In two cases, another method of suicide
was employed. In the first case, a 45-year-old man was found
hanging in a barn with a gunshot wound to his forehead and a rifle
nearby. Further scene investigation and autopsy findings verified a
self-inflicted, but not necessarily fatal gunshot wound. The bullet
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
garage. The deceased had an entrance wound to his temple. A .22-
caliber rifle was present at his feet. A penetrating gunshot wound
track shattered the base of his skull and perforated through the
bilateral basal frontal and right temporal poles and anterior pons.
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
present at the scene which the victim likely contemplated on using
if the hanging attempt was unsuccessful.
Restraints—In 17 cases, the deceased restrained themselves
by applying a ligature (same as used for hanging, a different
rope, or duct tape) to their wrists and/or ankles. All of the
deceased were males with average age of 38.1 years (from 16 to
66 years). All cases were concluded to be suicides. In 10 of the
cases, only the wrists were bound (including two cases in which
handcuffs were applied), in three cases, only ankles were bound,
and in four cases, both wrists and ankles were tied.
Other—In four cases, the male victims placed a plastic or fab-
ric bag over their heads. The bag application did not interfere
with breathing (excluding suffocation as a mechanism). Three
cases involved two females and one male who covered their
faces with some sort of fabric material. One male stuffed under-
wear into his mouth. Another male had a large amount of plastic
material taped in place over his mouth and inside his oral cavity.
One female had a scarf stuffed into the oral cavity. In four cases,
the deceased were wearing earphones or had earplugs (two
males and two females).
Seasonal Variation
Case distribution by month is shown in Fig. 2, combined for
the studied two-year period. When each year was analyzed sepa-
rately, hangings were most frequent in the spring of 1998 and in
the summer of 1999. For both years, the greatest number of
hangings occurred in May.
Other Injuries
In addition to the two above-described cases of firearms inju-
ries, a number of other injuries were present, the most common
being blunt force trauma (179 cases, 28.3%), predominantly
recent and minor.
In three cases, significant trauma was sustained as a result of
a fall from a broken noose. In one case, a 39-year-old man (Case
5 in Table 5) jumped from a 4.5- to 6-meter-high bridge with an
aircraft cable tied around his neck and the other end of the cable
secured to the bridge railing. As a result, he sustained a deep
4 JOURNAL OF FORENSIC SCIENCES
100
80
NUMBER OF CASES
60
40
20
0
Jan Feb Mar Apr May Jun Jul Aug
MONTH
FIG. 2––Seasonal case distribution.
laceration to the anterior neck with a complete transection of the
trachea, esophagus, and cervical spine. The ligature broke, and
the deceased was found on rocky ground, partially submerged in
a creek. He had scalp lacerations with extensive skull fractures
and cerebral contusions resulting from the fall. Although fall-
related trauma was significant and potentially fatal, he died from
severe neck trauma as a result of hanging. In addition to severe
head trauma, there were pulmonary contusions and a retroperi-
toneal hematoma. In the second case, a fall from a broken liga-
ture in a long drop case was associated with significant
perimortem abdominal trauma including retroperitoneal hema-
toma, lacerated liver, and adrenal gland with small hemoperi-
toneum (Case 3 in Table 5). In the third case, a fall from a
broken noose in the first unsuccessful hanging attempt resulted
in significant nonfatal head trauma including a parietal scalp lac-
eration with a skull fracture, contrecoup type cerebral contusions,
and mild acute subarachnoid hemorrhage.
Self-inflicted fresh incised wounds were observed in 42
(6.2%) suicides (wrists and forearms—36, neck—4, anterior
chest—1, lower extremities—1). One of the neck wound cases
also had a stab wound to the neck. Recent/healing neck incised
wounds were observed in two cases. Scars from prior cuts to
wrists and forearms were present in 61 cases. Two cases of heal-
ing stab wounds to the left chest were documented. All chest
and neck sharp force injuries were consistent with being self-
inflicted and nonfatal and present in males only. Fresh and old
cuts to extremities were more common in females.
In addition to the defined ligature mark to the neck, there
were abrasions along the ligature mark in 43 cases and bruises
along the mark in four cases (in two instances in addition to
abrasions). In two cases, there were superficial tears along the
ligature marks (one in a long drop and the second in an incom-
plete hanging of a teenager). In 10 cases, there were nonspecific
abrasions to the neck away from the mark and in five cases—
bruises. Two cases of distinct fingernail marks were documented
(both in males). All cases with the above additional neck find-
ings were suicides.
Toxicological Findings
Toxicologic testing was not performed in 23.6% of the cases.
In the suicidal hangings, 31.3% tested positive for ethanol and/
or illegal drugs and 5.3% showed toxicologically significant
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
cases.
Hanging-Related Neck Injuries
Hyoid and Laryngeal Fractures—Fractures of the hyoid bone
and/or laryngeal cartilages were reported in 46 cases (7.3%) of
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%).
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-
Sep Oct Nov Dec
ter cases: a 37-year-old woman hanging in a small space behind
a furnace; a 36-year-old man completely suspended with a thin
ligature; and a 27-year-old man suspended with a nylon rope
with his feet touching the floor. Apart from the recent incised
wrist wounds in the second case, no other injuries were docu-
mented.
Fractures of the left greater horn of the hyoid bone were
observed more frequently (17 cases vs. nine cases where the
right horn was broken). In three cases, hyoid horns were frac-
tured bilaterally, and in the remaining four cases, no comment
was made regarding the site of fracture. Right and left superior
thyroid horns were fractured with the same frequency (three
cases for each side) and in four cases bilaterally. In one case,
there was no comment identifying the site of injury. The lamina
of the thyroid cartilage was fractured in two cases. In three
cases, a complete transection of airways occurred.
Hemorrhage at the fracture site was described in 14 instances
of hyoid and seven of thyroid cartilage fractures, and was absent
in three and four cases, respectively. In the remaining 16 cases
of hyoid fractures and two cases of thyroid fractures, no com-
ment was made regarding the presence or absence of associated
hemorrhage. In three cases of cricoid cartilage fractures, no clari-
fication was provided whether the injury was hemorrhagic.
The incidence of fractures was higher in the older age groups
(Table 1). Frequency of both laryngeal and hyoid fractures was
significantly higher when older than 30 (p = 0.049).
Fractures were significantly more common (p = 0.028) in
males than females (Table 2). When stratified by age, no frac-
tures in females younger than 30 years were observed. There
was a 3.8% incidence in older women. Respective incidences for
males younger or older than 30 years were 5.2% and 9.7%.
Although the incidence of both hyoid and thyroid fractures was
much higher in males, one of three cricoid fractures was found
in a female.
When the distribution of neck injuries was evaluated in rela-
tion to the different institutions, the highest incidence was in
teaching hospitals (16.7%) and the lowest in the Provincial
Forensic Pathology Unit (PFPU) (2.8%). The incidence was
6.1% in community hospitals. The proportion of autopsied
females was the highest in the PFPU (35.2%) and the lowest in
teaching hospitals (14%). The higher proportion of autopsied
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-
nations only, and most of them (93.8%) were performed on
males. The mean age of the individuals who had complete
autopsies was 41.4 and 39.1 years in the PFPU and teaching
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
with no grossly apparent vascular tears, and a case of a torn
epiglottis. In two cases, there were unilateral and bilateral tears
of the sternocleidomastoid muscles (level not described). In addi-
tion, there were seven cases of tongue injuries (hemorrhages and
bite marks).
Role of Suspension Type—Information on the type of suspen-
sion was available for 57.6% of the autopsies (364 cases). Approx-
imately one-third of these (33.5%) were reported as complete
suspensions. The remainder (66.5%) of the deceased were incom-
pletely suspended. The incidence of laryngeal and hyoid fractures
was higher when suspension was complete (10.7% vs. 6.2%). A
similar tendency was observed for cervical spine injuries—the
incidence was twice greater in completely suspended individuals
(1.6% vs. 0.8%). Soft tissue injuries unrelated to skeletal fractures
were more common in incomplete suspensions (11.6% vs. 9.8%).
When the group of complete suspension cases was subdivided
into an “intermediate” group consisting of individuals whose feet
had a partial contact with the ground (toes/feet touching the
floor), this subgroup showed a similar distribution for all types
of injuries when compared to the complete suspension group.
Discussion
Hanging is one of the most common methods of committing
suicide. Numerous studies have been published regarding the
demographic parameters of hanging victims and the various
pathological findings observed in the course of postmortem
examination.
The typical hanging victim is a young or middle-aged male
with a history of prior mental illness and suicidal tendencies
who is found suspended in a secure location. Male predomi-
nance has been demonstrated in a number of previous studies
and was prominent in ours (comparative data between studies
presented in Table 7). The youngest individual to commit sui-
cide in this study was an 11-year-old boy, while 10-year-old
individuals were reported in other studies (12,17). A majority
of the suicide victims (78.6%) had a prior psychiatric history
with half of them having a history of prior suicidal tenden-
cies, prevalence higher than in other studies (31,32).
Although a vast majority of hanging deaths are suicides,
accidental hangings and homicides have also been reported.
Accidental hangings are uncommon, occurring up to 5% of all
hanging fatalities (33) and usually involve entanglement of
small children in ligatures while playing (30,34), experimental
behavior involving ligatures in older children (30,34), misad-
ventures in adults frequently related to unsafe surrounding envi-
ronment and intoxication (35,36), or autoerotic asphyxiation in
younger males (30,37). Of nine accidental deaths (1.2%) in our
study, a majority (six) involved children. Accidental hangings
in adults were related to entanglement in a ligature following
medical collapse and a fall. One accidental hanging involved a
young male with apparent erotic intent, yet lacking an escape
mechanism. No classical cases of autoerotic asphyxiation were
observed during the studied time period.
Homicidal hangings are extremely rare and should be distin-
guished from postmortem body suspension following a homicide
by other methods (1–6). Homicidal hangings are reported in
young children. When adults are involved, there are usually
signs of violence or incapacitation. In our study, two cases of
homicidal hanging were identified, both involving young girls
suspended by their mothers who had further taken their own
lives by hanging (dyadic murders).
A seasonal variation in suicides has been reported in several
past studies which show that suicides peak in spring and early
summer and dwindle in autumn and winter months (38–40).
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
showing the least prominent seasonal fluctuations (38). Some
seasonal variation in hanging deaths was observed in our study
with the highest incidence in May. Azmak (11) and Morild (23)
demonstrated a peak in spring–summer while other studies
(17,26,27) found no correlation. Interestingly, Guarner et al. (31)
found hanging fatalities highest in December.
Among the studied cohort, a number of unusual cases were
reported. Unusual circumstances will often raise suspicion of
foul play (41–44). Among these are combined suicides (also
called complex suicides) where multiple, frequently extreme,
methods of suicide are employed to protect against failure. We
observed two cases of unusual combined suicides where both
hanging and firearms were involved. Nonlethal fresh incised
wounds and intoxication are not unusual findings in cases of sui-
cidal hanging (12,42), and were observed in 6.2% and 36.6% of
cases in this study, respectively.
Rarely, restraints (wrist/ankle bounding) are used by the
deceased to prevent self-rescuing attempts (45,46). Occasional
cases of a mouth plug (likely in an attempt to prevent a cry for
help) are described (46,47). These cases raise suspicions of other
party involvement and require further investigation. We identi-
fied 17 suicidal hanging cases where hands and/or ankles were
bound and three instances of an oral plug.
Suicide pacts are rare, especially involving hanging (48). Dif-
ficulty might arise in determining the manner of death. Two
cases of double suicide, one involving teenage girls and the
other involving two male family members, were identified in our
study. Unusual places of hanging can also raise suspicion. For
example, rare cases of hanging inside a vehicle were reported in
the literature (49,50). Our study identified two suicidal hangings
in a car.
The frequency of laryngeal/hyoid fractures in the literature
ranges from 0% to 76.8% (9–11). This discrepancy is attributed
to variable population composition, lack of standard dissection
approach, different postmortem techniques employed (e.g., radio-
logical or stereomicroscopic examination), thoroughness of
assessment, and retrospective vs. prospective design of the study.
The frequency of laryngeal and hyoid fractures in our study was
significantly lower than in other studies. This difference could
be explained as combined effect of all of the above factors.
Fractured structures can be easily overlooked at autopsy (30).
Visual inspection and palpation alone miss a significant number
of injuries, and on occasion may lead to a false diagnosis of
fracture (22,30). Layered anterior neck dissection in an avascular
field (“dry neck” technique) with a careful dissection of hyoid–
larynx complex is generally accepted as an approach that yields
the most reliable results. The retrospective nature of this study,
however, did not allow us to evaluate the role of dissection
techniques in determining the incidence of fractures. The
autopsy reports documented use of a “dry neck” approach in a
small percentage of cases (9%) including only two cases with
fractures.
Like most of the other studies, we observed the incidence of
fractures to increase with age (7,14,15,17–21,23,24,26–29). The
age dependence is likely based on age-related fusion of the
hyoid joints, calcification and ossification of the laryngeal carti-
lages, and overall brittleness of bony structures with an older
age. Hyaline thyroid and cricoid cartilages undergo calcification
and ossification processes starting from the second decade and
advancing with age (51). Variations in ossification, however, do
exist based on other factors than age (individual health, genetics,
etc.) (51).
A higher incidence of neck fractures was observed among
males, a tendency similar to most prior studies
(7,15,18,20,24,27). A difference in the patterns of ossification
between males and females is thought to be a factor with
females having a slower rate of ossification. The patterns of ossi-
fication between genders, in general, diverge around the fifth
decade of life (51).
Gender difference in fracture incidence was further demon-
strated when evaluating different institutions performing medi-
colegal autopsies in Ontario. The difference in the frequency of
neck injuries was most significant between the PFPU (2.8%) and
the teaching hospitals (16.7%). The PFPU had the highest pro-
portion of autopsies on female victims.
In addition, there was a tendency for fractures to increase in
heavier individuals. Incidence correlated with both body weight
and BMI. A recent study performed by Clement et al. (15)
demonstrated a contributory role of weight, height, and BMI in
the incidence of fractures, with the difference remaining signifi-
cant when correlated with the age.
Eighteen unequivocal long drop hangings were identified
within our studied group. These showed a higher incidence of
hyoid–laryngeal fractures.
The contributory role of suspension type was both confirmed
(15,18,23,24,28) and rejected (21,26,29) in previous studies.
Luke et al. (28) concluded that complete suspension was a con-
tributing factor to fractures irrespective of age. We found it chal-
lenging to assess the data on suspension. The main challenges
were related to initial scene alteration by the finder of the body
and incomplete case information. Additional uncertainty came
from the fact that incomplete hanging might be, in fact, an evo-
lution of complete suspension where the ligature was further
stretched or the knot tightened under the effects of gravitational
forces in a completely suspended individual (52). To further
explore this, the cases where the feet of the deceased were only
in partial contact with the ground were analyzed separately. This
group showed tendencies similar to the complete suspension
group in relation to both skeletal and soft tissue injuries.
Although we did find fractures to be more common in complete
suspension and soft tissue injuries more frequent in incomplete
suspension, the assessment was limited by missing data. The
predominance of incomplete suspensions in this series might be
another factor to account for the lower incidence of neck inju-
ries. In Azmak’s study (11), the frequency of neck injuries was
the highest (76.8%). Most of the cases in that study (96.4%)
were complete suspensions.
The nature and relative position of the ligature and knot were
reported to play a role in some studies (18,24–27) and found
noncontributory in others (15,19,21,28,29). These factors were
not analyzed in the present study due to a lack of complete data.
Other factors that are potentially important such as the static vs.
dynamic nature of the force applied during neck constriction
(28,53) (slow neck compression vs. “jumping” into a noose)
could not be assessed in the present study.
One unusual finding in our study was a higher incidence of
cricoid fractures than reported in the literature. Cricoid fracture
is considered very unusual for suicidal or accidental hanging,
with only a few cases reported (14,24,29), while its incidence in
homicidal strangulation ranges between 5% and 20.6% (7). A
recent study by Godin et al. (7) specifically related to the com-
parative incidence of cricoid fractures in suicidal hangings vs.
homicidal strangulation deaths found only one instance of cri-
coid fracture among 2700 cases from previously published stud-
ies. This injury was proposed as highly suspicious and a
 TUGALEVA ET AL.
potential indicator of homicide. In Khokhlov’s study (22), the
frequency of cricoid fractures in hanging was reported as 9.5%
(13 cases). In his prospective study, the author employed stere-
omicroscopic examination of carefully skeletonized hyoid and
larynx specimens and found that the majority of cricoid injuries
were apparently inconspicuous (“fissures”).
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
hemorrhages while 14% were nonhemorrhagic. While some
studies identify hemorrhages at all fracture sites (12,17,22),
absence of vital reaction is not uncommon. Luke et al. (28)
found near half of detected fractures lacked soft tissue hemor-
rhage, which they attributed to possibly compromised circula-
tion at the fracture site due to locally increased pressure and
arterial compromise. Morlid (23) and Simonsen (27) concluded
that fractures often were not associated with hemorrhages.
Both studies demonstrated some increase in the frequency of
fractures with increasing length of suspension time, suggesting
that many fractures might be postmortem. Other proposed
explanations for the absence of hemorrhage at a fracture site
include the terminal events at the time of death (e.g., terminal
convulsive episode), postmortem body handling (ligature
removal, body transportation, etc.), or technical artifact created
by neck dissection (20,23,29). Green et al. (20) found frac-
tured neck structures in near half of their 40 prospectively
studied cases, yet only one with unequivocal hemorrhage. The
same study showed no postmortem dissection-related fractures
in their control group supporting their conclusion that dissec-
tion techniques were unlikely responsible for the fractures.
Rajs and Thiblin (54) studied histological appearance of frac-
tured thyroid cartilage and demonstrated that hemorrhages at
fracture sites were not always macroscopically evident;
hemorrhage was diagnosed microscopically in about third of
the fractures.
Cervical spine injuries are considered rare in suicidal hanging
(55) ranging from 0% to 9.9% (Table 7). They are more com-
mon in judicial type hanging where long drop is a factor.
Review of historical judicial hangings showed a variable propor-
tion of cases having cervical injuries at various levels with the
classical hangman’s fracture (C2 fracture dislocation through
bilateral pars interarticularis) being uncommon (56,57). In our
study, seven cases of cervical spine injuries (fractures or disloca-
tions) were documented, mostly involving the upper cervical
spine. Only two of them were associated with long drops. A sin-
gle case of hangman’s fracture was found in an incompletely
suspended young male. Asymmetric force distribution (subaural
knot) may have played a role.
Complete decapitation in hanging is rare and traditionally
related to judicial hanging when drop forces are underestimated.
Rare cases of suicidal hanging with decapitation are reported
(58–60). Forces involved are much greater and dependent on
length of drop and body weight and more likely to happen with
a relatively narrow and nonelastic ligature. One case of near-
complete decapitation was identified in our study which hap-
pened as a result of long drop.
In 7% of suicidal hangings, additional marks (irregular abra-
sions and occasional bruises) and two instances of distinct fin-
gernail marks were described along a ligature mark. These
injuries, referred to by some as “periligature injuries,” could be
attributed to the ligature application, attempts of the deceased to
release the constricting ligature, removal of the ligature by a res-
cuer, or resuscitation efforts (61). They should be distinguished
. RETROSPECTIVE ANALYSIS OF HANGING DEATHS 9
from injuries of concealed homicidal strangulation with post-
mortem body suspension.
Presence of other trauma was identified in a number of cases,
mostly minor blunt force injuries. Significant trauma related to a
fall from a hanging position (broken ligature) was present in
only three cases.
Conclusion
Because the large majority of hanging deaths are suicides,
determination of cause and manner of death is usually straight-
forward. On occasion, they can be a challenge when suspicions
of foul play are raised. Deaths occurring under special (e.g.,
deaths in custody or in a psychiatric facility) or unusual circum-
stances (very young victims, young individuals without a history
predictive of suicide, young women in an unsecure environment
discovered by a male partner, use of restraints or gags, autoerotic
deaths, double suicides, uncommon locations such as motor
vehicles, combined/complex suicides) were found in this study.
Such cases place the onus on the death investigation team to rule
out foul play. Depending on the circumstances, there may be
public demands for prevention of future deaths and even recom-
pense through legal avenues. The current approach to hanging
deaths in forensic pathology practice is the increasing use of
external examinations. Cases with complete autopsies tend to be
skewed to deaths occurring under special and unusual circum-
stances. This study reinforces previous literature in noting that
the presence and frequency of external and internal neck trauma
are determined by a complex interplay of multiple factors of
variable significance such as age, gender, body habitus, and
degree of suspension. Notably, this study showed that no frac-
tures occurred in females younger that thirty years of age.
Although cricoid fractures were rare and only observed in three
suicides, one was found in a woman. As reported in other litera-
ture on suicidal hangings, this study noted external trauma
remote from the ligature mark not only on the neck but also on
other areas of the body. Other unusual internal neck injuries
(e.g., cervical spine trauma) were observed. Our observations do
provide reassurance to the forensic pathologist that a spectrum
of injuries can occur in suicidal hangings. Their ultimate signifi-
cance in terms of manner of death is predicated by the totality
of the death investigation.
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Additional information and reprint requests:
Elena Tugaleva, M.D.
Department of Pathology and Laboratory Medicine, University Hospital
London Health Sciences Centre
339 Windermere Road
London, ON N6A 5A5
Canada
E-mail: elena.tugaleva@lhsc.on.ca