ORIGINAL ARTICLE
Hanging Deaths
A Retrospective Study Regarding 260 Cases
Maria Cristina Russo, MD, Andrea Verzeletti, MD, Mauro Piras, MD, and Francesco De Ferrari, MD
Abstract: Hanging is a form of asphyxia caused by external pressure on
the upper airways deriving from a band tightened by the gravitational
weight of the body. During a 33-year period from 1983 to 2015, there were
260 hanging deaths examined at the Brescia Institute of Forensic Medicine
(Northern Italy), which represented approximately 40% of all the asphyxial
deaths recorded during this period. Almost all of the cases were represented
by suicidal events, 1 case was a homicide event and there also was a case of
sexual asphyxia. Eighty-two percent of the victims were men; 18% were
women. There was an increasing tendency in the ages between 20 and
60 years, and the highest number of cases was observed in the 41- to
50-year age group (23% of the cases). The most common place chosen
by the victim was the home setting followed by isolated outdoor places.
The most common ligature material was a rope. The pathological findings
were evaluated in all cases.
Key Words: hanging, suicide, asphyxial death, pathological findings,
neck injuries
(Am J Forensic Med Pathol 2016;37: 141–145)
H anging is a form of asphyxia caused by external pressure on
the upper airways deriving from a band tightened by the grav-
itational weight of the body.
It is classified as complete when the whole body is suspended
and incomplete when suspension regards only part of the body.
When the loop of the ligature band lies on the anterior region of
the neck and the knot is on the back, hanging is defined typical;
all other conditions are defined as atypical. Hanging is a common
method of suicide, although, rarely, a murderer chooses hanging
to commit homicide. In a few cases, hanging occurs as an accidental
event. The aim of this study was to describe and characterize all the
hanging events reported at the Institute of Forensic Medicine in the
County of Brescia (Northern Italy) between 1983 and 2015, cov-
ering a 33-year period, focusing on socioepidemiological factors
and pathological findings of forensic interest.
MATERIALS AND METHODS
We retrospectively analyzed the postmortem examination re-
cords from the archive of the Brescia Institute of Forensic Med-
icine from April 1983 to May 2015. During this period, 260
hanging deaths were registered. The County of Brescia is an im-
portant industrial district in Northern Italy (Lombard region), with
a population of more than 1,250,000 (12.8% of the Lombard re-
gion's population; 2.2% of the Italian population). According to
Italian law, in all the cases, a forensic medical examination was es-
tablished by the prosecutor. An external examination was required
in 61 cases; autopsy in 199 cases.
Manuscript received October 30, 2015; accepted March 25, 2016.
From the Istituto di Medicina Legale, Università degli Studi di Brescia,
Brescia, Italy.
The authors declare no conflict of interest.
Reprints: Maria Cristina Russo, MD, Medicina Legale, Istituto di Medicina
Legale di Brescia, Piazzale Spedali Civili 1, Brescia, Italy.
E-mail: mariacristina.russo3@libero.it.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0195-7910/16/3703–0141
DOI: 10.1097/PAF.0000000000000239
Am J Forensic Med Pathol • Volume 37, Number 3, September 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
The data analyzed for each case included (1) year, month,
and day of the event; (2) information about the victims (sex, age,
nationality); (3) manner of death (suicide, homicide, accident);
(4) place of death; (5) type of hanging (complete or incomplete
suspension) and ligature mark (typical or atypical hanging, place-
ment of the ligature); (6) ligature means; (7) external findings (fa-
cial congestion, petechial hemorrhages of the conjunctive, tongue
position); (8) internal findings when autopsy was performed (frac-
ture of the hyoid bone and laryngeal cartilages; cervical fractures;
muscle neck hemorrhages; Amussat sign; petechial hemorrhages
of the pleura, pericardium, and scalp); (9) toxicological examina-
tion outcomes (whenever mandated by the law); and (10) psychi-
atric history, when known. The lack of some data (place of death,
type of suspension, ligature material) is because of the prosecu-
tor's decision that, according to Italian law, does not always require
a forensic pathologist at the scene of death. The forensic patholo-
gist reached the scene of death in less than 10% of the cases, with
the examination of the place of injury usually being performed by
the police forces whose data are not always included in the foren-
sic pathologist's report.
RESULTS
Year, Season, Month, and Day of the Event
In the 33-year period between May 1983 and April 2015, a
total of 11,670 postmortem examinations were carried out in our
Institute. Of these, 260 were hanging deaths that represented ap-
proximately 40% of all the asphyxial deaths. An increasing ten-
dency was recorded in the last 2 decades with a peak between
2000 and 2002 (approximately 23% of all events) (Fig. 1). The
highest frequency was registered in November (11%), followed
by April and June (10% of the cases) (Table 1) (Fig. 2); of the
weekdays, most cases occurred on a Monday (18%).
Victims' Characteristics
In 212 hanging cases, the victim was a man (82%), with
a male-to-female ratio of 4:1. The 31- to 50-year age group
accounted for the most number of cases (121 cases, approximately
46%). There were extremes in age, those younger than 20 years
and older than 80 years comprised 5% and 3% of victims, respec-
tively. The youngest victim was a 13-year-old boy and the oldest
was a 95-year-old man (Fig. 3).
Most of the victims were Italian (87%); foreigners repre-
sented 13% of the cases.
Place of Death
This information was not available in 49 cases; for the rest,
the most common place chosen by the victim was the home setting
(70% of the cases) followed by isolated outdoor places (15%).
In 8 cases, the suicide event occurred at the workplace; in 6
cases, the victim was a prisoner in the county jail; 5 events oc-
curred in a hospital regarding mostly psychiatric patients; 5 vic-
tims committed suicide in a public place (eg, railway station,
public toilet); whereas 2 truck drivers killed themselves in their
own trucks (Table 2).
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Russo et al
FIGURE 1. Temporal distribution of hanging deaths.
Type of Hanging and Ligature Mark
Data regarding the type of suspension (complete or incom-
plete) were available in 177 cases; of these, complete hanging rep-
resented 71%. In approximately 77% of the cases, the hanging
was typical, and the knot was localized on the back of the neck.
In approximately 22% of the cases, the knot was located on the lat-
eral region of the neck, whereas in 3% of the cases, the knot was
on the front side.
The mark was mostly present as a single loop (95% of the
cases). In 26% of the cases, the mark was continuous; in all the
other cases, the sign had one or more interruptions (usually in
the back according to the knot position).
The mark was usually oblique from bottom to top and from
front to back (96%), and in 62% of the cases, the ligature mark
was above the thyroid cartilages.
Ligature Means
Data regarding the ligature material were available in 156
cases: of these, rope was the most common material used by the
victims (approximately 58% of the cases); in the other cases, the
victims chose cables, belts, scarf, foulards, chains, strings, ties,
sheets, drapes, or clothes (eg, trousers, sweaters) (Table 3).
External Findings
Facial congestion was observed in approximately 12% of the
cases. Conjunctival petechiae were seen in approximately 11%
and protruding tongue in 19% of the cases.
Internal Findings
An autopsy was performed in 199 cases. The study revealed
that 66% of the cases (132) had internal neck structures injuries.
Muscle neck hemorrhages were observed in 50% of the
cases, tears of the intimae carotid (Amussat sign) in 17% of the
cases, hyoid bone fractures in 17% of the cases, laryngeal carti-
lages fractures in 15% of the cases, and fractures in the cervical
vertebrae in 4% (Table 4).
Petechial hemorrhages were revealed on the scalp in 56% of
the cases, on the pleura in 34% of the cases, and on the pericar-
dium in 15%.
TABLE 1. Distribution of Cases According to Season
Season No. Cases %
Spring 73 28
Summer 67 26
Autumn 67 26
Winter 53 20
Total 260 100
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Am J Forensic Med Pathol • Volume 37, Number 3, September 2016
Toxicological Examination Outcomes
Toxicological examinations were performed in 94 cases
(47%) of all the autopsies. Among these, alcohol was tested in
43% of the cases and was found in half. Illegal drugs were tested
in 37% of the cases and had a positive result in 30% (68% cocaine,
14% cannabinoids, 9% oppioids). Drugs were tested in 56 cases
(28%) and were found in only 6 (almost all antidepressants).
Psychiatric History
A history of pathological illness was documented in only 65
cases (approximately 25%). Frequently, the victims experienced
depression, anxiety, or paranoid schizophrenia.
Manner of Death
Almost all of the cases were represented by suicidal events
(98.8%). There were 2 cases of accidental events and only 1 homi-
cide case (Table 5).
About the accidental events, 1 could be classified as sexual
asphyxia: a 50-year-old man died during a bondage sex game.
The man was found naked in his bedroom with a rope tightened
around the neck and fixed to the door handle. Toxicological anal-
ysis revealed that he was under the influence of alcohol.
The second accidental event involved an old woman while
she was sleeping: it represents an atypical form of external pres-
sure on the neck by a protective corsage worn by the woman.
Probably, the woman made inappropriate movements during the
night that dislocated the corsage, and so she hanged herself by
the weight of part of her body.
Lastly, the homicide case concerned a young foreign woman
(aged 20 years) who was killed in an isolated place, hanged to a
roof beam using a sweater with her hands tied behind her back.
Blunt extracranial injuries were observed on the victim; no alcohol
was detected in her blood.
DISCUSSION
Hanging is a form of asphyxial death frequently adopted as a
suicide method. Our retrospective analysis conducted in Brescia
County in a 33-year period (1983–2015) revealed that almost all
FIGURE 2. Distribution of hanging deaths per month.
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Am J Forensic Med Pathol • Volume 37, Number 3, September 2016 Hanging Deaths

TABLE 3. Ligature Material Used to Hang

Ligature Material Number %

Rope 91 58.3
Cable 17 10.9
Soft tissue (eg, sheets, drapes) 10 6.4
Belt 10 6.4
Scarf 7 4.5
FIGURE 3. Distribution according to age groups. Shutter belt 5 3.2
String 4 2.6
the hanging deaths that occurred were suicide events (257 cases), Bathrobe belt 2 1.3
according to other international studies.1–8 Chain 2 1.3
In 2 cases, hanging was an accidental event, and 1 case was Clothes 2 1.3
represented by homicidal hanging. As reported in the literature, Foulard 2 1.3
homicidal hanging is a rare event8–12; it is usually used by a mur- Tie 2 1.3
derer after strangulation to simulate a suicidal event committed by Tube 1 0.6
the victim. Corsage 1 0.6
Moreover, accidental hanging is not a frequent event. Many
Total 156 100
authors described accidental autoerotic hanging deaths13–15 (sim-
ilar to the case we reported) and accidental hangings in the pediat-
ric population16,17 (no cases involving children happened during Most of the victims were Italians (87%); foreigners repre-
the considered period). sented 13% of the cases. The first foreign victim was reported in
The phenomenon of hanging has been increasing in the last 1997, and the number has gradually grown according to the in-
2 decades, with a peak in the early years of the 21st century. A creasing migratory flow, reaching a peak in 2009.
similar trend was observed in other countries, whereas there The most common place of death was the victim's own home
was a decreasing trend in other Italian counties (Roma)18 and followed by isolated outdoor places, according to other similar
international countries.19,20 studies.2,19,24,25 When a person decides to kill himself or herself,
In most of the cases, the victim was a male adult. The male- 2 scenarios usually are recurrent: when the need for a familiar
to-female ratio was 4:1, showing that a higher tendency to commit place or the wish to be found by relatives or friends to hit or shock
suicide by hanging was associated with the masculine sex as what them is prevalent, the home setting is the place of choice; when in-
has resulted in almost all published studies.4,6,19–24 stead, guilt, shame, or the need for isolation are the main sensa-
Generally, hanging increases with age, with a higher percentage tions, the victim prefers outdoor places far from home.
in the 31- to 50-year age group both for men and women. The age Complete suspension was the leading manner of hanging.
groups between 21 to 30 and 61 to 80 years displayed a markedly This finding is consistent with what is described in other re-
different trend between sexes with a much higher male-to-female ports2,4,19,22,26: complete hanging seems to better assure death
ratio (approximately 10:1). The preponderance of adult male vic- because it requires a single act, differing from incomplete sus-
tims reflects the findings of most international reports.6,19–24 pension that seems more difficult to realize and apparently re-
There was no significant seasonal variation. We registered a quiring a stronger will and a prolonged act.
higher number of victims in spring and a slight decrease in winter. In approximately 77% of the cases, the hanging was typical.
Most of the victims committed suicide on a Monday (18%), as This is in contrast to information reported by Sharma et al22 and
noted by Suárez-Peňaranda et al.4 It could be explained by the Dean et al.23
feelings connected to the beginning of the working week: fatigue Usually, the ligature mark was oblique from bottom to top
caused by the need for planning the whole week, busyness, and and from front to back (96%) and was above the thyroid cartilage
the distance from weekend rest for the working population. For (in 62% of the cases). This finding reaffirms itself as one of the
unemployed people, other factors might play a role like stress re- main pathognomonic signs of hanging differing from ligature
lated to the search for a job or depression caused by the absence of
an active role in society.
TABLE 4. Internal Neck Structure Injuries (199 Cases)

TABLE 2. Distribution of the Cases According to Place of Death Neck Structure Injuries No. Cases %
Hyoid bone fractures 34 17
Place of Death Number %
Hyoid bone 5
Home 148 70 Greater horns 27
Outdoor place 31 15 Lesser horn 2
Workplace 8 4 Thyroid cartilage fractures 30 15
Jail 6 3 Body 9
Indoor place 6 3 Superior horns 20
Public place (eg, railway station) 5 2 Lesser horn 1
Hospital 5 2 Muscle injuries 100 50
Truck 2 1 Tears to the intimae carotid 34 17
Total 211 100 Vertebral fractures 7 4

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Russo et al Am J Forensic Med Pathol • Volume 37, Number 3, September 2016

the characteristics of the ligature sign is very important to diag-

TABLE 5. Summary Characteristics of Hanging nose hanging. According to these results, the ligature mark has
to be considered as the leading forensic sign to diagnose and dif-
Variable No. cases %
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