Abstract
We report an atypical case of suspension death involving chest compression. A 41-year-old male was found suspended from the veranda of his residence by means of multiple woollen shawls tied together to form an improvised rope. Autopsy revealed mechanical asphyxia as the cause of death with no evidence of foul play. The death was accidental, most likely due to the deceased’s attempt to descend from the first floor by rope. This case highlights the need to carry out meticulous death scene investigations and autopsy examination to identify unusual suspension mechanisms, particularly in accidental deaths.
Keywords
Case presentation
A 41-year-old male was found fully suspended from his veranda in a rural municipality of Palpa District, Nepal. He had knotted multiple woollen shawls together and fixed this improvised rope to an iron beam on the first floor (Figure 1). Notably, the ligature encircled the thoraco-abdominal region with the neck extended.
Death scene of a 41-year-old male found hanging by rope from the veranda of his residence. The body is fully suspended by a ligature material around the chest.
Autopsy findings
External examination
The deceased was of average build, height 5 feet 2 inches. There was fixed livor mortis and contact pallor posteriorly. The body was cold and stiff.
The most notable external finding was an incomplete pressure abrasion encircling the thoraco-abdominal region, suggestive of significant compressive force. This abrasion extended forward and upward from the back, and was incomplete over the front of the chest. No other significant external injuries were noted except for a needle prick mark over the left forearm laterally, 2.5 cm above the left wrist.
Internal examination
Internal examination revealed cerebral oedema and generalised visceral congestion, with petechial haemorrhages. All the organs were congested on the cut section. The liver showed congestion with fatty changes. No trauma or haemorrhage was noted in neck structures. Stomach contained semi-digested yellowish liquid-like material with identifiable rice particles. The sternum and ribs were intact. Due to limited mortuary resources, the vertebral column was not dissected.
Toxicological analysis
Stomach contents and samples of liver, kidney, and blood were collected and preserved in appropriate media for toxicological analysis. The laboratory report was negative for common poisons.
Case history
As the circumstances were unusual, the death scene was examined. To determine the manner of death, a psychological autopsy was conducted, involving interviews with the deceased’s family which revealed that the deceased was a chronic alcoholic. He had been admitted and treated with intensive care support for 10 days and discharged only a day before the incident. The family had a tradition of making arrack (homemade brewery) at home. The wife reported that her husband insisted on consuming alcohol on the evening of his discharge. To prevent her husband from gaining access to the kitchen on the ground floor, she locked the first-floor entrance before she went out of the house for cattle fodder and firewood. There was nobody present in the house at the time of the incident. It was suggestive that the husband tied the shawls together with a white rope secured to the iron beam on the first floor to descend to the ground floor. Unfortunately, the improvised rope was too short and he ended up completely suspended by the chest. The psychological autopsy and police inquest revealed no foul play and death was deemed to be accidental due to positional asphyxia.
Discussion
This case features atypical chest suspension, different from neck compression typical in hangings which involves neck compression leading to death through various mechanisms, including vascular occlusion, airway compression and vagal stimulation, whereas suspension by the chest restriction respiration and causes thoracic compression. 1 Chest suspension restricts breathing through mechanical splinting, a phenomenon also observed in a Lithuanian case where torso deformation led to asphyxia. 2
Extended neck position analysis
The extended neck position is pertinent; it suggests the victim was conscious during suspension, likely maintaining airway patency. 3 Conscious individuals preserve airway patency through muscle tone and reflexes, avoiding chin flexion which would obstruct the hypopharynx by the root of the tongue. 4 Extension of the neck would oppose this, consistent with rescue manoeuvres that lift the tongue from the pharyngeal wall to restore breathing. 4 With complete suspension in a thoraco-abdominal ligature, the head could fall forward or backward, depending on the tilt of the body relative to the suspension point. The observed extension suggests that the torso is inclined posteriorly, pulling the head backward or ligature tension restricts forward collapse. However, given the victim’s history of chronic alcoholism and recent hospitalisation, prolonged battle with his body weight most likely led to exhaustion. As he lost consciousness the tone of the skeletal muscle diminished, and gravity kept the head in an extended position, anchored by the mechanics of suspension and the ensuing rigor mortis. This progression, from active survival response to passive gravitational effect, underscores the dynamic interaction of physiology and position in atypical suspension deaths, distinguishing it from typical unconscious airway collapse where flexion predominates. 4
To analyse this unusual case of death by chest suspension, let us analyse the key findings for a deeper understanding of the mechanism and manner of death:
Complete suspension with chest compression
Incomplete pressure abrasion encircling the chest (indicating significant compressive force)
Congestion of internal organs
Cerebral oedema
No significant neck trauma or injuries
No rib fractures
Mechanism of death
The primary mechanism appears to be related to mechanical asphyxia through several potential pathways 5 :
Respiratory compromise: Chest compression limited thoracic expansion, impairing breathing, worsened by body weight in full suspension. Extended neck position suggests conscious attempts to maintain airway
Circulatory impairment 6 : Thoracic compression reduced venous return, causing organ congestion and cerebral oedema. Possible compromise of the vertebral artery due to neck extension.
Contributing factors:
Contributing factors to positional asphyxia often include intoxication or incapacitation, affecting self-extrication. In a series of 37 cases of positional asphyxia reviewed by Chmieliauskas et al., alcohol intoxication was identified in 45.9% of victims with a mean blood alcohol concentration of 2.5 g/L, sufficient to prevent escape efforts. 2 Although our case had negative toxicology, the chronic alcoholism of the victim and recent hospital discharge suggest a potentially compromised state, potentially exacerbating vulnerability to suspension. This aligns with the findings that underlying conditions, even without acute intoxication, can make people vulnerable to such deaths. 7 The contextual history – being locked in on the first floor and trying to descend – favours an accidental scenario driven by impaired judgment, possibly linked to alcohol-seeking behaviour.
The absence of rib fractures is noteworthy and may be attributed to 8 :
- The distribution of pressure across a wider area due to the shawls
- The gradual application of force during suspension
- Possible protective effect of clothing
Manner of death:
The evidence strongly supports accidental death:
- Extended neck suggests active respiratory compensation
- Scene evidence of attempted descent
- No defensive injuries
- No tentative or hesitation wounds
- Recent hospital discharge and alcohol-seeking behaviour provide a clear context
- No signs of struggle or restraint
Conclusions
Postmortem findings are consistent with the unconventional means of suspension from the chest. It is suspected that death resulted from mechanical asphyxia, with pressure abrasion indicating restricted breathing. Toxicology rules out intoxication. The psychological autopsy showed no suicidal intent and underlines the importance of a comprehensive death scene investigation and a full autopsy in an atypical suspension death. The unusual nature of the case paralleled with the scarce literature dealing with chest suspension deaths emphasises the importance of detailed documentation, particularly through images, to enhance diagnostic precision and guide future investigations of similar atypical suspensions.
Footnotes
Acknowledgements
The authors acknowledge the Investigating Officer for providing the death scene photographs.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
