Forensic Science International 301 (2019) e44–e48

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Forensic Science International

journal homepage: www.elsevier.com/locate/forsciint

Case Report

Differentiation of homicidal or suicidal strangulation

E. Doberentz* , P. Markwerth, B. Madea
Institute of Legal Medicine, University of Bonn, Stiftsplatz 12, 53111, Bonn, Germany

A R T I C L E I N F O A B S T R A C T

Article history: Hanging can be suicidal, accidental, or homicidal, and these backgrounds must be discriminated by police
Received 25 April 2019 and forensic pathologists. We herein report a case involving a 33-year-old man who was found dead on
Received in revised form 29 May 2019 the floor behind the entrance door of an apartment house. The man’s brother declared that he had found
Accepted 31 May 2019
him hanging in the gap between the stairs on the top floor. When his brother tried to cut him down, the
Available online 8 June 2019
victim fell three floors down through the gap between the stairs. Autopsy was performed to confirm
suicidal hanging and a postmortem fall into the narrow gap. In this case, however, a homicide was
Keywords:
suspected, and the version of events told by the victim’s brother was initially doubted. Homicidal hanging
Fall
Hanging
may be uncommon, but intensive scene investigation and thorough autopsy are necessary in hanging
Homicide cases to rule out homicide.
Strangulation © 2019 Elsevier B.V. All rights reserved.
Suicide

1. Introduction whose offenders have superior physical force [8,14,22]. However,

About 95% of all hanging cases have a suicidal background [1]. This
can be problematic because although the number of suicidal hangings
is much higher than that of accidental or homicidal hangings, many
cases of non-suicidal hanging nevertheless point toward suicide, and
the external postmortem examination and police investigation may
therefore be inadequate. Furthermore, a court order to perform an
autopsy may be omitted in these ‘clear’ cases.
Accidental hanging [i.e., Refs. [2–9]] accounts for approximately
5% of all hanging cases [1,10]. Most such cases involve infants, and
some involve adults engaging in autoerotic behaviour. All three
types of hanging (accidental, homicidal, and suicidal) occur in
children, but infants can also commit suicide [11]. It is sometimes
very difficult or even impossible to clarify the manner of death
[12]. In cases of accidental sexual asphyxia, the place of discovery
and typical findings such as pornographic equipment may point to
an autoerotic death. These cases could have legal relevance
because another person is likely involved in autoerotic behaviours
and homicides may simulate sexual asphyxia [13].
Homicidal hanging is very rare. A German study performed 35
years ago estimated a homicidal hanging incidence of 1:1000 [14].
The estimated number of undetected cases might be higher, which
may be caused by the low autopsy rate. A few cases of homicidal
hanging have been reported in both older and more recent
literature [8,10,14–21]. Hanging can be the form of homicide itself;
this is mainly found in children, incapacitated people, or victims
* Corresponding author.
E-mail address: edoberentz@uni-bonn.de (E. Doberentz).
postmortem hanging after homicide is also possible [14,18,23,24].
Such cases may involve hanging of the victim in the agonal period,
but before death [20].
The classification of a suicidal, accidental, or homicidal hanging
can be challenging, especially in cases of ambiguous circumstances
[12,16,19,25,26]. We herein present an unusual case of suicidal
hanging that led immediately to the suspicion of homicide. This
case demonstrates the importance of a thorough crime scene
investigation and cooperation between police and forensic
pathologists at the crime scene as early as possible.
2. Case report
2.1. History
The police were called, and a man reported that he had found his
brother hanging in the staircase outside of his apartment. When the
police officers arrived at the scene, the man’s 33-year-old brother
was found dead behind the entrance door of an apartment house on
the ground floor (Fig. 1). The man declared that he had found his
brother hanging in the gap between the stairs (Fig. 2). A belt had been
attached to the handrail of the banister on the top floor where the
man’s apartment was located. When trying to cut his brother down,
the victim fell three floors down through the gap between the stairs.
The man was questioned by the police. He said that his brother
was on a visit and that they had been drinking alcohol the previous
evening and went to sleep before midnight. He did not see his
brother until he found him at 05:00 the next morning. In contrast,
neighbours told the police that they still heard the two brothers
speaking in the early morning.

https://doi.org/10.1016/j.forsciint.2019.05.058
0379-0738/© 2019 Elsevier B.V. All rights reserved.
 E. Doberentz et al. / Forensic Science International 301 (2019) e44–e48 e45

Fig. 1. Original position of body at the time of discovery. The body was in the supine position directly behind the entrance door. Parts of a belt were present beside the head.

Fig. 2. View through the gap between the stairs to the top of the staircase where the brother found the man strangulated and freely hanging in the gap.
e46 E. Doberentz et al. / Forensic Science International 301 (2019) e44–e48
The police officers were suspicious because of the contradictory
information regarding the time of death. Additionally, it seemed
impossible to fall more than three floors from the top to ground
floor through the very narrow gap between the stairs (Fig. 3) and
land in the position in which the deceased was found. Moreover,
the back of the victim’s head showed an injury (Fig. 4). A homicide
was therefore suspected, and the version of events provided by the
victim’s brother was doubted. Forensic pathologists were imme-
diately called to the scene.
2.2. Autopsy findings
The deceased was a man with a body weight of about 80 kg and
a body length of 176 cm. He had a normal stature.
At the scene, livores were present on the face and back of the
body, and the legs showed a stocking-like appearance of livores.
During the autopsy, intense livores were found on the back of the
body, and a few livores were present on the front of the legs. The
external examination revealed a single semi-circular strangulation
mark on the neck, rising to the right back aspect of the neck. This
mark corresponded to the structure of the belt and contained
reddish–brownish dried excoriations due to the prominent belt
margins and the metallic eyelets (Fig. 4). The man had a pale face
without petechial haemorrhage in the facial skin, conjunctivae, or
oral mucosa. The tongue was protruded between the teeth.
A 1-cm reddish-livid excoriation was found on the top of the
head. The right back region of the head exhibited a transversal 4-
cm-long linear and deep laceration of the scalp (Fig. 4). The upper
margin of the wound was undermined for 1 cm. Haemorrhage was
absent from the subcutaneous tissue of the scalp, particularly in
the area of the laceration.
The front of the right shoulder and the left calf contained
reddish-livid haematomas of 1.5 cm. The right lower leg beneath
the patella showed small whitish shreds of the epidermis with the
direction of the impact towards the head without subcutaneous
haemorrhage. The skin of the lower right tibia was also excoriated
with epidermal shreds with basis in direction toward the head and
with without subcutaneous haemorrhage.
The internal examination revealed a small area of haemorrhage
in the right temporal muscle. The brain weighed 1.440 g. The lungs
were emphysematous and congestive (left, 610 g; right, 530 g) and
Fig. 3. The narrowest diameter of the gap was 22 cm.
touched over the mediastinum. Both upper horns of the laryngeal
cartilage were fractured and exhibited minor haemorrhage. The
hyoid bone was intact, and no haemorrhage was present in the
tissue of the neck. Simon’s bleedings were not present.
2.3. Further investigation results
Histological examination of organs taken at autopsy revealed
lung congestion and chronic hepatitis. Immunohistochemical
investigation of the ligature mark showed an intense positive
reaction of aquaporin 3 staining in the epidermis and dermal blood
vessels (Fig. 5).
The alcohol concentration was 0.89m in the femoral venous
blood and 1.21m in the urine. Chemico-toxicological investigation
revealed no influence of psychoactive drugs.
The time of death was determined to be around midnight.
3. Discussion
In Germany, 4512 people died of suicide by hanging,
strangulation, or suffocation in the year 2015 [27]. Of these
people, 80.42% were male and ten were aged 10–15 years. Schmidt
et al. [28] described a 10-year-old girl who committed suicide by
hanging, and the parents simulated homicide to hide the suicide.
Interestingly, in both males and females, the incidence of suicidal
strangulation increases with age and peaks between 50–60 years,
then decreases.
Hanging results in strangulation with compression of the neck
and disturbance of the cerebral blood flow due to the victim’s own
body weight. Various factors must be considered when investi-
gating hanging cases to discriminate among suicidal, accidental,
and homicidal hanging, such as:
 Motive of suicide
 Reconstruction of the mechanism of strangulation and proof of
the possibility of self-strangulation
 Determination of the cause of death
 Proof of vital strangulation
 Assessment of all injuries
 Further chemico-toxicological analysis regarding the ability to
act
 E. Doberentz et al. / Forensic Science International 301 (2019) e44–e48 e47

Fig. 4. Strangulation mark corresponding to the belt and pale face. The right side of the back of the head contained a linear laceration.

Fig. 5. Ligature mark, aquaporin 3-positive reaction, 200.

In the present case, the brother’s story and the odd fall into a narrow
gap of a staircase led to the suspicion of homicide. The inspection of the
scene by forensic pathologists was useful to reconstruct the circum-
stances of death. The original suspension was not objectively witnessed
by anyone but the man who found his strangulated brother. The suicide
was unexpected and apparently without motive. The man had used his
own belt of about 90 cm in length, which was reportedly attached to the
handrail of the banister on the top floor. Traces of material such as paint
that had rubbed off on the handrail were not found. The ligature mark
rose to the back of the head. Livores were present in a circular pattern on
the dependent body parts, which is consistent with a suspended
position. The pale face without congestion and the protruded tongue
corresponded to typical hanging. Broken upper horns of the laryngeal
cartilage with slight surrounding haemorrhage are also typical findings
in suicidal hanging [29]. In a recent study, 33.7% of 178 hanging victims
exhibited isolated laryngeal fractures without involvement of the hyoid
bone. The wide ligature mark on the neck corresponded to the belt with
the highest pointof suspension at the right aspectof the backof the head.
Histological examination of the ligature mark revealed intense
staining of the water channel aquaporin 3 in the epidermis,
indicating a vital injury to the skin of the neck [30,31]. Ishida et al.
immunohistochemically investigated 56 cases of neck compres-
sion and found markedly intense positive signals in dermal
keratinocytes in the compressed regions. Depending on the case,
the ligature mark can show vital reactions if the victim was still
alive when suspended during the agonal period [20].
The gap between the stairs was only about 22 cm wide. Thus,
the man had to climb over the banister and lower himself into the
narrow gap. In postmortem hanging, the corpse has to be moved
and placed in the position of strangulation. The body is heavy, and
e48 E. Doberentz et al. / Forensic Science International 301 (2019) e44–e48
characteristic findings are therefore usually present at the scene
and on the body [24,32] (e.g., variable excoriations of the skin or
signs of pulling up the victim on the rope). Popp reported two cases
in which grooves in branches proved that the corpses had been
pulled up into the hanging position with a rope [33].
After the man in the present case found his brother strangulated
in the morning, he cut the belt. The body fell down and had to pass
several stairs from the third floor to the bottom with the risk of
impact or even becoming stuck. A postmortem reflexless direct
vertical fall with only minor contact was possible in this narrow gap.
The presence of avital headward-directed excoriations of the skin
would have corresponded to a fall down the staircase. Convulsions
due to suffocation in a cramped environment can also cause injuries
by striking walls or objects [8]. Sauvageau et al. investigated the
incidence of haematomas of the upper and lower limbs in hanging
cases with a focus on the location of hanging compared with
homicidal strangulation cases [23]. They found haematomas in 66.7%
of the cases involving hanging in staircases. The incidence of
haematomas was significantly lower in hanging victims (19.8%) than
in homicidal strangulation victims (55.6%). Signs of violence that do
not correspond to the hanging are characteristic in such cases
[14,19,20]. Additionally, injuries can be missing in cases of
unconsciousness due to alcohol or drug intoxication.
The linear avital injury at the back of the head could have
resulted from impact of the head on the edge of the lateral steps
during the fall or from impact on the edge of the last step of the
stairs, where the victim was found. Because of the lack of
cardiovascular circulation, only a small amount of blood was found
on the floor under his head. The scalp did not show haemorrhage.
This case involved an avital fall from a height of about 9 m with
intermediate impacts that did not cause severe injuries.
The autopsy and further investigations did not reveal findings
inconsistent with suicidal hanging and a postmortem fall from
height. The brother reported alcohol drinking the evening before
death. The victim had a blood alcohol concentration of 0.89m at the
time of death. There was no suspicion of unconsciousness.
Additionally, the determination of death correlated with the time
of death after the reported drinking.
Finally, suicide by hanging could be conclusively justified.
4. Conclusion
The most common form of hanging is suicidal. Although
homicidal hanging is uncommon, an intensive police investigation
of the scene, involvement of forensic pathologist in the scene
investigation, and thorough autopsy and further investigations are
necessary to rule out homicide in hanging cases.
Conflict of interest
None.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
CRediT authorship contribution statement
E. Doberentz: Conceptualization, Data curation, Investigation,
Writing - original draft, Writing - review & editing. P. Markwerth:
Investigation, Data curation. B. Madea: Supervision, Writing -
review & editing.
References
[1] D.A. Bowen, Hanging—a review, Forensic Sci. Int. 20 (1982) 247–249.
[2] A.N. Vadysinghe, M. Sivasubramanium, R.P. Jayasooriya, A tree branch instead
of a ligature: an unusual accidental hanging, Forensic Sci. Med. Pathol. 13
(2017) 441–443.
[3] S. Kodikara, Accidental hanging: a novel mobile suspension apparatus partially
hidden inside the clothes, Am. J. Forensic Med. Pathol. 33 (2012) 311–313.
[4] Y. Ueno, M. Asano, H. Nushida, K. Nakagawa, J. Adachi, Y. Nagasaki, Sexual
asphyxia by hanging—a case report and a review of the literature, Leg. Med.
(Tokyo) 5 (2003) 175–180.
[5] E. Gok, S. Cetin, E. Baduroglu, R. Fedakar, O. Akan, N.E. Saka, Two accidental
hanging cases of children, J. Pak. Med. Assoc. 65 (2015) 790–792.
[6] R. Fedakar, O. Akan, B. Eren, Autoerotic asphyxia by hanging, J. Pak. Med. Assoc.
58 (2008) 462–464.
[7] M.K. Egge, C.D. Berkowitz, C. Toms, L. Sathyavagiswaran, The choking game: a
cause of unintentional strangulation, Pediatr. Emerg. Care 26 (2010) 206–208.
[8] D.N. Vieira, A.E. Pinto, F.O. Sá, Homicidal hanging, Am. J. Forensic Med. Pathol. 9
(4) (1988) 287–289.
[9] S. Pollak, Zur Verkennung des Erhängungstodes bei der ärztlichen Leichen-
schau, in: E. Schlüchter (Ed.), Kriminalistik und Strafrecht: Festschrift für
Friedrich Geerds, Schmidt-Römhild-Verlag, 1995, pp. 455–469.
[10] C.T. Cooke, G.A. Cadden, J.M. Hilton, Unusual hanging deaths, Am. J. Forensic
Med. Pathol. 9 (1988) 277–282.
[11] J.P. Wyatt, P.W. Wyatt, T.J. Squires, A. Busuttil, Hanging deaths in children, Am.
J. Forensic Med. Pathol. 19 (1998) 343–346.
[12] K. Wöllner, G. Kernbach-Wighton, B. Madea, Suicide in childhood or accidental
hanging? A case report, Arch. Kriminol. 236 (2015) 43–50.
[13] R.K. Wright, J. Davis, Homicidal hanging masquerading as sexual asphyxia, J.
Forensic Sci. 21 (2) (1976) 387–389.
[14] K. Püschel, W. Holtz, E. Hildebrand, W. Naeve, B. Brinkmann, Erhängen: Suizid
oder Tötungsdelikt, Arch. Kriminol. 176 (1984) 142–153.
[15] F.C. Monticelli, H. Brandtner, S.N. Kunz, T. Keller, F. Neuhuber, Homicide by hanging:
a case report and its forensic-medical aspects, J. Forensic Leg. Med. 33 (2015) 71–75.
[16] D. Geisenberger, S. Pollak, A. Thierauf-Emberger, Homicidal strangulation and
subsequent hanging of the victim to simulate suicide: delayed elucidation based
on reassessment of the autopsy findings, Forensic Sci. Int. 298 (2019) 419–423.
[17] S. Pollak, A. Thierauf-Emberger, Homicidal assault to the neck with subsequent
simulation of self-hanging, Forensic Sci. Int. 253 (2015) e28–e32.
[18] H.J. Mallach, S. Pollak, Simulated suicide by hanging after homicidal
strangulation, Arch. Kriminol. 202 (1989) 17–28.
[19] A. Sauvageau, True and simulated homicidal hangings: a six-year retrospective
study, Med. Sci. Law 49 (2009) 283–290.
[20] P. Leth, A. Vesterby, Homicidal hanging masquerading as suicide, Forensic Sci.
Int. 85 (1997) 65–71.
[21] Y. Ueno, T. Fukunaga, K. Nakagawa, T. Imabayashi, S. Fujiwara, J. Adachi, Y. Mizoi, A
homicidal strangulation by ligature, disguised as a suicidal hanging, Nihon Hoigaku
Zasshi 43 (1989) 46–51.
[22] E.O. Lew, Homicidal hanging in a dyadic death, Am. J. Forensic Med. Pathol. 9
(1988) 283–286.
[23] A. Sauvageau, A. Godin, S. Desnoyers, C. Kremer, Six-year retrospective study of
suicidal hangings: determination of the pattern of limb lesions induced by
body responses to asphyxia by hanging, J. Forensic Sci. 54 (2009) 1089–1092.
[24] A. Werkgartner, Tötung an der Ehefrau durch Erwürgen und Vortäuschung
eines Selbstmordes durch Erhängen. Zugleich ein Fall von Sarggeburt, Dtsch. Z.
Ges. Gerichtl. Med. 7 (1926) 424–441.
[25] K. Yamamoto, T. Hayase, H. Matsumoto, Y. Yamamoto, Suicidal hanging or
simulated suicide? Once again a case of Kobue: a spectacular case in the
history of Japanese legal medicine, Arch. Kriminol. 201 (3–4) (1998) 97–102.
[26] C. Behera, R. Rautji, R. Kumar, S. Pooniya, P. Sharma, S.K. Gupta, Double hanging
with single ligature: an unusual method in suicide pact, J. Forensic Sci. 62
(2017) 265–266.
[27] Cause-of death statistics Germany 2015, published 19.01.2017, https://www.
destatis.de/DE/Themen/Gesellschaft-Umwelt/Gesundheit/Todesursachen/
Publikationen/Downloads-Todesursachen/todesursachen-2120400157004.
pdf (accessed, 11.06.2019).
[28] P. Schmidt, F. Driever, B. Madea, Simulation of homicide to hide child’s suicide,
Arch. Kriminol. 208 (2001) 54–61.
[29] L. Zátopková, M. Janík, P. Urbanová, J. Mottlová, P. Hejna, Laryngohyoid
fractures in suicidal hanging: a prospective autopsy study with an updated
review and critical appraisal, Forensic Sci. Int. 290 (2018) 70–84.
[30] Y. Ishida, Y. Kuninaka, M. Nosaka, E. Shimada, S. Hata, H. Yamamoto, Y.
Hashizume, A. Kimura, F. Furukawa, T. Kondo, Forensic application of
epidermal AQP3 expression to determination of wound vitality in human
compressed neck skin, Int. J. Legal Med. 132 (2018) 1375–1380.
[31] Y. Ishida, Y. Kuninaka, F. Furukawa, A. Kimura, M. Nosaka, M. Fukami, H. Yamamoto,
T. Kato, E. Shimada, S. Hata, T. Takayasu, W. Eisenmenger, T. Kondo, Immunohisto-
chemical analysis on aquaporin-1 andaquaporin-3 in skinwounds from the aspects
of wound age determination, Int. J. Legal Med. 132 (2018) 237–242.
[32] B. Mueller, Erstickung, in: B. Mueller (Ed.), Gerichtliche Medizin, 2. Aufl.,
Springer, Berlin, Heidelberg, New York, 1979, pp. 439–468.
[33] G. Popp, Mord oder selbstmord bei aufgehängten Leichen, Arch. Kriminol. 88 (1931).