International Journal of Psychiatry in Clinical Practice

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Suicide and undetermined death by drowning

Emad Salib & Norman Agnew

To cite this article: Emad Salib & Norman Agnew (2005) Suicide and undetermined death
by drowning, International Journal of Psychiatry in Clinical Practice, 9:2, 107-115, DOI:
10.1080/13651500510018257

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Published online: 12 Jul 2009.

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International Journal of Psychiatry in Clinical Practice, 2005; 9(2): 107
/115

ORIGINAL ARTICLE

Suicide and undetermined death by drowning

EMAD SALIB1 & NORMAN AGNEW2

1
Liverpool University, 5 Boroughs Partnership Trust, Warrington, UK, and 2Hollins Park Hospital, Warrington, UK

Abstract
Background. Incidence of drowning varies among countries and even communities within the same country. The manner of
death may remain undetermined even when the diagnosis of drowning is confirmed or excluded. It is expected that
drowning suicide rates in some of the available studies may have been over- or under-reported because of
misclassification. Objectives. This study presents data on the time trends, age/sex mortality rates from death by drowning
in England and Wales between 1979 and 2001. All coroners’ verdicts in death by drowning; suicide, deaths undetermined
whether accidentally or purposely inflicted were examined. Methods. Counts of suicide due to drowning and submersion
(ICD 9 codes; E954) and undetermined injury deaths (E984) [1], reported in England and Wales between 1979 and 2001
were obtained from National Statistics (ONS). National population estimates were used to calculate age-specific rates and
age-standardised rates of death by drowning. Results. Over the last 23 years, there has been a gradual and significant
reduction in drowning deaths. The decline in drowning suicide was less evident in the elderly, particularly those over the age
of 75. During the study period, 62 and 38% of all death by drowning attracted an open verdict and suicide, respectively.
Elderly drowning appear to attract more verdicts of suicide compared to younger age groups (odds ratio 4.3, 95% CI 2.3
/
8.3). Women, particularly elderly, are more likely to have a suicide verdict returned in drowning compared to men (odds
ratio 1.5, 95% CI 1.1
/1.6). Conclusion. The high rate of open verdicts in death by drowning over the study period and
compared to any other method of fatal self harm in England and Wales confirms the difficulties in reaching a firm conclusion
in drowning death. Combining suicide and all undetermined deaths in drowning in nationally collected statistics may result
in grossly exaggerated rates and misleading trends in suicidal drowning.

Key Words: Drowning, suicide, drowning suicide, trends in drowning, undetermined drowning

Introduction given a suicide verdict, with more than 70% being

Incidence of drowning varies among countries with
reported rates ranging between 3 and 26% of total
suicide. Table I presents summary of comparative
rates of drowning in nine studies from different
countries between 1984 and 2001. Drowning in
these studies referred to suicide and undetermined
death combined. It has been proposed that part of
the reason for this variation is accessibility to water,
with higher drowning rates in areas adjacent to the
sea or large lakes [2]. Access to other methods of
suicide has also been suggested to explain differences
in the choice of method in fatal self-harm [3].
Drowning is one of the leading causes of death
when the manner of death remains undetermined
[4]. Lunetta et al [5], in a 25-year review of
drowning deaths in Finland, reported that drowning
was the second leading cause of undetermined
death, with only 23.9% of drowning deaths being
confirmed as suicide. Kelly and Bunting [6] reported
that 30% of deaths from drowning were actually
given an open verdict in their 15-year review of
suicide in England and Wales. Similar findings were
reported by Gamcro [7] based on a 27-year review of
drowning in Spain. In the investigation of a body
found in water, a wide range of possibilities other
than drowning have to be considered [8].
The diagnosis of drowning itself may be difficult
as there are no specific diagnostic features at autopsy
[5,8,9]. This is usually established through critical
evaluation of the victim’s individual characteristics,
the circumstances, autopsy findings and other in-
vestigations. The Gettler chloride test which com-
pares chloride levels in blood from the right and left
side of the heart is not considered reliable and other
electrolyte assessments are not helpful [8].
Even when the diagnosis of drowning is confirmed
or excluded, the manner of death may remain
undetermined [5]. Therefore it is possible that
some studies reported a falsely low rate because
of misclassification of disguised drowning as acci-
dental or undetermined death [10]. Another area of

Correspondence: Emad Salib, MB, MSc, MRCPI, FRCPsych Hollins Park Hospital, Warrington WA2 2WA, UK. E-mail: esalib@hotmail.com

(Received 10 March 2004; accepted 9 December 2004)

ISSN 1365-1501 print/ISSN 1471-1788 online # 2005 Taylor & Francis
DOI: 10.1080/13651500510018257
108 E. Salib & N. Agnew
Table I. Comparative studies of suicide by drowning.
to the registration office for the district where the
death occurred. The Office of National Statistics
Percent of
(ONS) coded causes of death mentioned on the
drowning
Author Country of total suicide Year death certificate to International Classification of
Diseases, Ninth Revision ICD-9 codes. ICD-10 has
Kelly & Bunting [6] England and 6 1998 been used since 2001.
Wales Counts of suicide due to drowning and submer-
Byard et al. [9] Adelaide, South 3.6 2001
Australia
sion (ICD 9 codes; E954) and undetermined injury
Davis [24] South Florida 2.86 1999 deaths (E984) (WHO 1977), reported in England
Copeland [23] Dade County, 4.5 1989 and Wales between 1979 and 2001 were obtained
Florida from National Statistics (ONS). ONS National
Auer [2] South Finland 7.9 1990 population estimates were used to calculate age-
Rockett et al. [26] Japan 7.3 1993
Avis [13] Newfoundland 8.9 1993
specific rates and age-standardised rates of death by
Romero [27] Sevilla, Spain 10 1989 drowning.
Cairns et al. [25] Aukland, New 26.7 1984
Zealand
Definition of drowning
In this study, the term drowning refers to: inten-
possible under reporting homicidal drowning, may tional (suicide verdicts), accidental or undetermined
not be correctly classified if police investigations do self-harm by drowning and submersion (open ver-
not reveal suspicious circumstances [11]. dicts) combined.
This study presents data on the time trends, age/
sex mortality rates from death by drowning in Data analysis
England and Wales between 1979 and 2001. All
Goodness-of-fit x2 was used to compare observed
coroners’ verdicts in death by drowning; suicide,
and expected counts of monthly and annual total
deaths undetermined whether accidentally or pur-
suicide, and drowning. Annual variations in suicide
posely inflicted were examined.
by drowning, expressed as counts and also as age-
Standardised rates were assessed by Control Charts
statistics.
Method
Design
Control Chart. (Run Charts) offers an application of
An observational study using routinely collected
time-series methods to assess the occurrence of
data.
suicide over a period of time, based on the Poisson
mean in which the variance is equal to the mean (C )
Data collection and standard deviation equal to square root of the
average C , i.e.
All deaths in England and Wales, which are violent,
pffiffiffiffi
unnatural, suspicious or unexpected, are referred to o? C
the coroner for further investigations. Unless the pffiffiffiffi
coroner is satisfied that the death was due to natural upper control limit /C 3 C ; lower control limit /
pffiffiffiffi
causes a post mortem is carried out. After taking into C 3 C :
account the pathologist’s report and any additional Variation in data over a period of time is assessed
information, such as police reports, the coroner will within an upper control limit (UCL) and lower
decide the cause(s) of death and give a verdict. A control limits (LCL) [11]:
verdict of suicide will be recorded if there is a clear
evidence, beyond all reasonable doubt, that the UCL Mean3 standard deviations LCL
individual intended to kill himself and that death  Mean3 standard deviations:
was self inflicted. If there is insufficient evidence to Between UCL and LCL it is expected that 99% of
state categorically that the intention of the indivi- total data and its variability would occur by chance.
duals was to take their own life, then an open verdict Observed suicide data that fall outside the UCL and
may be returned. Similarly, there may be others for LCL are unlikely to have occurred by chance (P B/
whom there is no direct evidence that they intended 0.01) and indicate significant deviation from the
to take their own life; however, the circumstances of expected. A Poissson regression model was also used
the death are such that it is apparent that there was a to calculate Rate Ratios with 95% Confidence
deliberate act, which resulted in death. In the Intervals for annual occurrence of elderly drowning
absence of apparent intent to die, a verdict of over the 23-year study period, using 1979 as the
misadventure or accident might be returned. The reference category. Egret and SPSS statistical
coroner certifies the death using Form 99 that is sent packages were used in the data analysis.

Figure 1. Drowning and total suicide in England & Wales 1979
/2001.
Results
Between 1979 and 2001 there were 129,244 inci-
dents of suicide (E950
/959) and other deaths from
injuries, undetermined whether accidentally or pur-
posely inflicted (E980
/989); 90,094 (70%) and
39,150 (30%), respectively. Drowning accounted
for 10,092 deaths (7.8%), the fourth most common
suicide for men and women of all ages, with 3786
(38%) verdicts of suicide and 6239 (62%) open
verdicts. Drowning accounted for 13.5% as third
cause of death of total elderly suicide, 16% for
women as the second cause of death after overdose
in elderly female suicide and 12% for men, fourth
cause of death in elderly male suicide. The propor-
tion of suicide and open verdicts varied considerably
between methods of suicide with a much higher
percentage of open verdict being recorded in drown-
ing (62%) compared to other methods: 12% in
Figure 1a. Age-Standardised Rate of drowning in England & Wales 1979
/2001.
Suicide and undetermined death by drowning 109
hanging, 35% in overdose, 31% in poison by gas,
13% in wounding, 6% in asphyxia, 12% in shooting,
42% in falling from heights, 45% in burning and
37% in all other methods (P B/0.05). Of the total
drowning, 5870 (58%) occurred in men and 4222
(42%) in women. Mean age was 55.7 (SD 18)
significantly higher in women than men; 57 (SD 16)
and 53 (SD 18), respectively (P B/0.05). In persons
aged 60 and above, there were 4736 (47%) drowning
incidents, with 2399 (51%) occurring in men and
2337 (49%) in women, compared with 3471 (65%)
male and 1885 (35%) female in persons younger
than 60. Significantly fewer females, younger than
19, committed suicide by drowning (5%) compared
to men of the same age and females in other age
groups (P B/0.05).
Figure 1 shows counts of total suicide compared
to drowning for each year since 1979, with gradual
reduction over the study period. Figure 1a shows the
110 E. Salib & N. Agnew

Figure 2. Average annual drowning by age groups and population in England & Wales 1979
/2001. Age-Specific Rate of drowning per
1,000,000 population.

age-standardised rate (ASR) for male and
female drowning, with significantly higher annual
mean values of 8.2 (SD 6) drowning per million
for men (min 6, max 12) and annual mean value
of 2.2 (SD 1; min 1, max 4) per million for
women (P B/0.05). The figure also seems to
suggest that the reduction in drowning for both
sexes was more evident in mid 1980s. However,
over the last 15 years, the variations in the age-
standardised rate for drowning around the expected
mean, particularly in the elderly over 75, occurred
within the range of the 95% UCL and LCL,
suggesting that such changes occurred by chance
with no statistical evidence of any significant reduc-
tion (P /0.05). Figure 2 shows number of suicides
and corresponding ASR for drowning per million as
distributed within age groups for the entire study
period, with significantly higher values of 16, 18 and
12 drowning per million for older age groups (P B/
0.05). Table II shows comparative counts and ASR
by age groups for the most common methods of
suicide in England and Wales, with a similar pattern
in overdose and drowning within different ages
groups.
Figure 3 shows the distribution of drowning by
gender for each year of the study period, with
consistently significant higher frequency in men
(P B/0.05). In comparison with other methods,
Figure 4 indicates a gradual increase in drowning
with age for both sexes, but more noticeable in
women after the age of 50.
Drowning appears to show seasonal variations,
evident in men and women (goodness-of-fit x2 /60,
df 11, P B/0.001), with higher frequencies in
March, April and May than would be expected by
chance (Figure 3a). Figure 5a shows the annual
variations in the percentage of suicide verdicts
returned by the coroners in drowning, with a clear
downward trend over the 23-year study period.
Significantly higher proportions of elderly drowning
appear to attract verdicts of suicide compared to
younger age groups (odds ratio 4.3, 95% CI
2.3
/8.3). Women, particularly elderly, appeared to
be more likely to have a suicide verdict returned
in drowning compared to men (odds ratio 1.5, 95%
CI 1.1
/1.6). Whilst Table III and Figure 6 illustrate
the gradual reduction in male and female numbers
of suicide by drowning starting from 1993, with
a significantly reduced Rate Ratio of 0.33 in 2001,
30% of the observed count in 1979 (P B/0.01),
Figure 5b clearly demonstrates the steady rise
in open verdicts over the same period, more evident

Table II. Age-specific rate (per 1,000,000) of common of methods suicide by age groups in England and Wales, 1979
/2001.

Age group ASR drowning (n ) ASR hanging (n ) ASR overdose (n ) ASR CO poisoning (n )

B/20 1 (173) 5 (1543) 4 (703) 4 (1195)

20
/30 5 (672) 35 (5291) 31 (3349) 39 (5330)
30
/40 6 (803) 28 (4823) 30 (3842) 35 (5452)
40
/50 8 (926) 26 (3774) 36 (3479) 29 (4651)
50
/60 10 (948) 24 (3243) 31 (2525) 18 (2944)
60
/70 16 (1027) 21 (2563) 42 (1971) 14 (1559)
70
/80 18 (873) 20 (1715) 40 (1401) 12 (909)
/80 12 (743) 15 (743) 30 (624) 10 (328)

Figure 3. Drowning by Gender in England & Wales 1979
/2001.
in the deceased younger than 60, a significant
positive time series trend (P B/0.01). The trend in
returning open verdicts is quite the opposite to
that of suicide verdicts during the same period
(Figure 5a).
Of the 10,092 deaths, 2807 (29%) had an addi-
tional ICD9 code recorded other than the code
for submersion (Table IV). Mental disorders were
mentioned only on 5% of death certificates, of
which ICD9 311 (depressive disorder) appeared on
the vast majority of 540 cases. In 4% of cases, ill-
defined physical conditions were mentioned and
terminal conditions such as malignancy appeared
on 2% of death certificates. It must be noted,
however, that information recorded on death certi-
ficates were only available from 1993 onwards, so
data related to 1979
/1992 was either missing or
incomplete.
Figure 3a. Seasonal variations in drowning by gender in England & Wales 1979
/2001.
Suicide and undetermined death by drowning 111
Discussion
Methodological limitations
The study presents national figures on death from
drowning in England and Wales, and therefore
presents data from a much larger population than
other studies. However, it must be stated that
mortality data in their present form were compu-
terised by ONS in 1993, so data before such date
may not have the same consistency with information
based on date of registration of death rather than the
year when death actually occurred. Although the
nationally collected routine data from ONS was
accepted as reliable and as complete as it would be
possible, a number of demographic and mental
health variables were not available, thus limiting
the scope of the study. Ethnic origin of the deceased
is not collected at death registration. Also the data
112 E. Salib & N. Agnew
Figure 4. Proportion of elderly male and female drowning within age groups in England & Wales 1979
/2001.
did not adequately cover three areas that could have
an important association with drowning; death due
to natural causes, alcohol and unlawful killing.
However every effort was made to include as many
valid records as possible from the ONS mortality
database.
Interpretation of the findings
Drowning is the fourth favoured method of suicide
for all ages and the third most common of suicide in
the elderly population in England and Wales. The
results of the study indicate that suicide rates from
drowning increased with age, and this is seen in
overall suicide rate in older persons [6]. The increase
in drowning rates with age was particularly marked
in women, in whom drowning is the second favoured
method of self-harm after overdose. There was an
Figure 5a. Trends in Coroner’s suicide verdicts (E954) in deaths by drowning in England & Wales 1979
/2001.
almost equal proportion of men and women in the
older age group who drowned, but the percentage
was significantly higher in men at 65%, compared to
35% in women aged less than 60. In this study the
mean age of all cases at 55.7 was not dissimilar to
56.1 reported in South Australia [13], with higher
mean age for women (57) than men (53), similar to
Auer’s [2] figures of mean age of 50 for men and 60
for women. While males may predominate in terms
of numbers, as a choice suicidal drowning is
favoured by females 50 years of age and older in
almost all available studies. It is interesting to note
that very few females between 15 and 18 used
drowning as method of suicide compared to males
(5 and 95%, respectively), similar to previous find-
ings by Byard et al. [9]. Seasonal variations in
drowning was evident in both sexes with increased
frequency in March, April and May not dissimilar to
 Suicide and undetermined death by drowning 113

Figure 5b. Trends in verdicts of undetermined deaths by drowning (E984) in England & Wales 1979
/2001.

studies from Belgium [14], the United States [15] Unfortunately the three areas that could have an
and in Cheshire, UK [16], but unlike Lunetta et al. important association with drowning deaths were
[5] who reported higher frequency of drowning in not adequately covered by the available data; death
the cold season in Finland. due to natural causes, alcohol-related drowning and
As a method of suicide, drowning was found to be unlawful killing. In these cases, drowning may have
the fifth preferred method in persons with mental been wrongly classified as suicide or accidental
illness, accounting for less than 4% of total suicide death.
by this group in England and Wales [17]. Despite the (1) It is difficult to determine whether underlying
fact that suicides of people with mental health natural diseases played a role in death by drowning,
problems account for 24% of total suicide in wrongly regarded as deliberate self-harm [18]. In
England and Wales [17], in this study only 5% of some of the victims, especially the elderly may have
death certificates reported mental disorder. died of natural causes. There are some examples of
this; ‘sudden death in bathroom’ (SDB) has been
Table III. Trends in death by drowning in England and Wales reported [19] occurring mostly in winter, and 80%
1979
/2001 (Poisson regression model). of cases were elderly persons while bathing. Cardiac
arrest and subsequent drowning in bathtubs were
Drowning Rate 95% Confidence attributed to sudden reduction in blood pressure and
(count) ratio interval Year cardiac arrhythmia and not due to fatal self-harm
[19]. Drowning has also been attributed to ‘sudden
329 1 Reference 1979
Category unexpected death in epilepsy’ (SUDEP) either
365 1.12 0.95
/1.3 1980 subsequent to a seizure or occurring suddenly with-
306 0.93 0.8
/1.1 1981 out explanation [20].
339 1.03 0.88
/1.2 1982 It may be relevant to note that in a local study in
323 0.98 0.84
/1.4 1983
297 0.90 0.77
/1.1 1984
Cheshire, UK [21], bathroom drowning accounted
250 0.76 0.67
/1.7 1985 for 7% of all elderly drowning, some of whom may
296 0.89 0.76
/1.8 1986 have died suddenly in water in similar manner as in
264 0.80 0.68
/1.1 1987 SDB. Also, nicotinamide deficiency, similar to
270 0.82 0.69
/0.9 1988 pellagra, has been reported in developed countries,
202 0.61 0.52
/0.7 1989
211 0.64 0.54
/0.7 1990
especially in alcohol-dependent people with poor
164 0.49 0.41
/0.6 1991 eating habits and self neglect, malabsorption, malig-
169 0.51 0.42
/0.6 1992 nancy and nutritional deficiencies [22]. It may be
152 0.46 0.38
/0.5 1993 reasonable to assume that some elderly people,
134 0.40 0.33
/0.5 1994
especially those who live alone may be vulnerable
127 0.38 0.31
/0.5 1995
108 0.33 0.26
/0.4 1996 to develop similar mental and physical changes of an
102 0.31 0.25
/0.4 1997 easily overlooked nicotinamide deficiency that could
100 0.30 0.24
/0.4 1998 result in accidental drowning, which is not uncom-
108 0.36 0.26
/0.4 1999 mon in endemic pellagra, but wrongly regarded as
101 0.33 0.26
/0.4 2000
suicide. It is interesting to note that Lunetta et al. [5]
100 0.30 0.24
/0.4 2001
reported that 2.6% of bodies found in water in their
114 E. Salib & N. Agnew

Figure 6. Trends in death by drowning in England & Wales 1979
/2001. Poisson regression model using 1979 as a reference category for
Rate Ratios.

25-year review of drowning in Finland were found to
have died of natural causes after an initially sus-
pected suicide.
(2) There were not sufficient data to make any
conclusion about alcohol or the use of illicit and
prescription drugs in this study. Death certificates
referred to only 5% prevalence of mental disorder,
all of which was related to depression with very little
reference to alcohol. The role of alcohol in drowning
is unclear, with conflicting and contradictory reports
from different studies. Concomitant alcohol use was
found to be uncommon [2,9,13], with reports of 20,
9 and 18% of drowning suicide to have tested
positive for alcohol, but Copeland [23] and Lunetta
et al. [5] reported much higher rates of alcohol-
associated drowning at 41 and 48%, respectively. In
contrast, accidental drowning was found to be
Table IV. Number of death by drowning and diagnoses recorded
on death certificates.
associated with positive blood alcohol [5,13] and
with alcohol and psychotropic medication among
those who committed suicide in the bath [9,10].
Davis [24] reported that the presence of alcohol was
less usual in the elderly than younger suicide victims,
which may explain the higher numbers of open
verdicts in drowning suicide in the younger age
groups.
(3) Homicidal drowning, which was not explored in
depth in this study, was reported in 1:1000 drowning
deaths, much lower when compared to 4:1000,
3:1000 and 8:1000 reported in other studies from
New Zealand, Spain and Finland, respectively
[5,7,25]. Modell and Davis [11] stated that homici-
dal drowning might not be correctly classified if
police investigations do not reveal suspicious cir-
cumstances. So it is possible that the rate of unlawful
killing by submersion (E964) may be generally
underestimated.

Chapters and diagnostic Number of Conclusion

categories of ICD 9
ICD 9 code:
E954 Suicide by submersion
(drowning)
E984 Selfinflicted injury by submersion
(undetermined whether accidentally
or purposely inflicted)
E964 Homicide and injury inflicted by
submesion other persons
ICD9 Chapter:
XVI Symptoms, signs and ill defined
conditions
VII Diseases of the circulatory system
VIII Diseases of the respiratory syatem
II Neoplasms
IX Diseases of the digestive system
V Mental disorders
VI Diseases of the nervous system
suicides by drowning
Over the last 23 years, drowning has declined
3786
steadily and significantly in men and women by
more than a third of 1979 counts. This decline was
6239 less evident in the elderly, particularly those over the
age of 75. The significantly high rate of open verdicts
96
in death by drowning over the study period and
compared to any other method of fatal self harm in
England and Wales, simply confirms the difficulties
440 in reaching a firm conclusion in drowning death.
The reduction in suicide verdicts over the last 23
710
596 years may have been due to an actual reduction in
160 suicide by drowning, but it is possible that such
225 reduction might be, at least partly, the result of an
540
increased trend in returning open verdicts by the
136
coroners.

It is clear from the study that combining suicide
and all undetermined deaths in drowning as a matter
of course, especially in nationally collected statistics,
may result in grossly exaggerated rates and mislead-
ing trends in suicidal drowning.
Unlike most other methods of suicide, the profile
of the typical suicidal drowning victim is relevant
only to the location in which drowning took place
and that generalisations should be made with cau-
tion. Suicide by drowning is probably not amenable
to prevention and although the elderly are more
often thought to benefit from suicide prevention
than younger adults, the study findings seem to
suggest that this is not likely to be the case in
drowning.
Key points
. The significantly high rate of open verdicts in
death by drowning over the study period and
compared to any other method of fatal self
harm in England and Wales, simply confirms
the uncertainties in reaching a firm conclusion
in drowning death
. The reduction in suicide verdicts over the last
23 years may have been due to an actual
reduction in suicide by drowning, but it may
be also the result of an increased trend in
returning open verdicts by the coroners
. Suicide by drowning is probably not amenable
to prevention and, although the elderly are
more often thought to benefit from suicide
prevention than younger adults, the study find-
ings seem to suggest that this is not likely to be
the case in drowning
Acknowledgements
The authors would like to thank Mrs Janice Hogan,
Sanofi, Mrs Jean Moxey and Mrs Judith Eden,
Pearsley Cross Hospital, St Helens, for their kind
support.
Statement of interest
The author has no conflict of interest with any
commercial or other associations in connection with
the submitted article.
References
[1] World Health Organisation. Manual of the international
statistical classification of diseases, injuries and causes of
death, Vol 1, 9th revision. Geneva: WHO; 1977.
Suicide and undetermined death by drowning 115
[2] Auer A. Suicide by drowning in Uusimaa Province in
Southern Finland. Med Sci Law 1990;8(1):175
/9. / /
[3] Lester D. The suicide rate by drowning and the presence of
oceans. Percept Motor Skills 1989;69(1):338. / /
[4] Ohberg A, Lonnqvist J. Suicides hidden among undeter-
mined deaths. Acta Psychiatr Scand 1998;98:214
/8. / /
[5] Lunetta P, Smith G, Pentilla A, Sajanntila A. Undetermined
drowning. Med Sci Law 2003;43:207
/14.
[6] Kelly S, Bunting J. Trends in suicide in England and Wales,
1982
/96. Population Trends 1998;92:29
/41.
/ /
[7] Gamcro JJ. A study among the population of Sevilla of death
due to submersion. Am J Forensic Med Pathol 1997;12(1): / /
70
/4.
[8] Knight B. Immersion deaths. Forensic pathology, 2nd ed.
London: Arnold; 1997. p 391
/406.
[9] Byard RW, Houldsworth G, James RA, Gilbert JD. Char-
acteristic features of suicidal drowning: a 20 year study. Am J
Forensic Med Pathol 2001;22(2):134
/8. / /
[10] Nowers MP. Suicide by drowning in the bath. Med Sci Law
1999;39:349
/53.
/ /
[11] Modell JH, Davis JH. Electrolyte changes in human drown-
ing victims. Anaesthesiology 1969;30:414
/20. / /
[12] Wetheril GB, Brown DW. Statistical process control, theory
and practice. London: Chapman & Hall; 1994.
[13] Avis SP. Suicidal drowning. J Forensic Sci 1993;38(6): / /
1422
/6.
[14] Maes M, Cosyns P, Meltzer HY, De-Meyer F, Peeters D.
Seasonality in violent suicide but not in nonviolent suicide or
homicide. Am J Psychiatry 1993;150(9):1380
/5. / /
[15] McCleary R, Chew KS, Hellesten JJ, Flynn-Bransford M.
Age and sex specific cycles in United States suicides 1973
/
1985. Am J Public Health 1991;81(11):1494
/7. / /
[16] Salib E, Gray N. Weather conditions and suicide. Br J
Psychiatry 1997;170:473
/7. / /
[17] Department of Health. Safer services; National Confidential
Inquiry into Suicide and Homicide by People with Mental
Illness. DoH K73/001 March 1999.
[18] Byard RW, Markopoules D, Prasad D. Early adolescent
suicide: a comparative study. J Clin Forensic Med 2000;17: / /
6
/9.
[19] Yoshioka N, Chiba T, Yamauchi M, Monma T, Yoshioki K.
Forensic consideration of death in the bathtub. Legal Med
2003;5(Suppl 1):375
/81.
/ /
[20] Lathers CM, Schraeder PL. Clinical pharmacology: drugs as
a benefit and/or risk in sudden unexpected death in epilepsy?
J Clin Pharmacol 2002;42(2):123
/36. / /
[21] Salib E, El Nimr G, Rahim S, Habeeb B. Elderly suicide: an
analysis of 200 cases in Cheshire 1989
/2001. Med Sci Law
2005;45:71
/80.
/ /
[22] Kumar P, Clark M. Clinical Medicine Bailliere Tindall
London Chapter III; 1994. p 163
/4.
[23] Copeland AR. Suicide by drowning. Am J Forensic Med
Pathol 1987;8:18
/22.
/ /
[24] Davis LG. Suicidal drowning in South Florida. J Forensic
Sci 1999;44(5):902
/5.
/ /
[25] Cairns FJ. Death from drowning. NZ Med J 1984;97(749):
/ /
65
/7.
[26] Rockett IR, Smith GS. Covert suicide among elderly
Japanese females: Questioning unintentional drowning. So-
cial Sci Med 1993;36(11):1467
/72. / /
[27] Romero JL. The evolution of suicide occurring in the city of
Sevilla between 1978
/1987. Rev Esp Med Leg 1989;16:9
/ / /
21.