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2 (4.8%) "Suspicious" Suicides included self-inflicted injuries, drug overdose and drowning. Accidents (2 falls, 1 drowning, 1 CO poisoning,

1 epileptic). Natural deaths —

cardiac. 19 accidental deaths caused by CO poisoning reflecting nature of heating system. Most of the suicides had toxic levels of alcohol and sedatives. Natural deaths —

2 seizure-related, 1 cardiac disease.

North Carolina, 70 1982-1983; (67 in bathtub, Shkrum and 2 in whirlpools, Hudson 1 in Jacuzzi)

59 adults, 44% 11 children (31)

"Nine did not have toxicological analysis; 42 assigned accurate manner. N, natural; A, accident; S, suicide; H, homicide; U, undetermined.

(25) (8) (4) (2) mirrored the overall frequency in the general population investigated under medicolegal jurisdiction.

Natural—mainly ischemic heart disease.

Accident—see Subheading 13.1.

Suicide—4 gunshots, 4 drownings.

Homicide—

2 strangled/drowned, 1 child drugged and drowned, 1 child delivered in tub and asphyxiated in plastic bag.

Fig. 15. Drowning in bathtub. Seizure disorder. Lip contusion.

Epileptics are at risk for drowning in bathtubs, particularly when unsupervised (103,112,131,179). Of eight bathtub drownings in Maryland, six had a seizure history (11). Seven of 17 epileptics who drowned in the Sacramento County series died in the bathtub (30). Of five epileptics in a New Zealand series who drowned, one died in the bathtub (33). Gardner and Devos et al. mention two seizure cases each (172,175). A Canadian series showed that 60% (15 of 25) of epileptics who drowned were taking an unsupervised bath (132). An epileptic can be found slumped over the edge of the tub (131). Although showering reduces the risk, drowning can still occur if the individual collapses and plugs the drain (132). Other potential injury scenarios include falling and striking the shower enclosure or other fixtures, and inadvertently striking the hot water faucet while having a seizure (132). Seizures while in the bathtub may not leave signs of a struggle or evidence of splashed water—i.e., seizure activity is not necessarily manifest as involuntary muscle contractions (112). Biting during a seizure can cause lip injuries. The tongue may be lacerated (Figs. 15 and 16). An autopsy does not always reveal definitive neuropathological findings (e.g., temporal sclerosis) indicative of epilepsy, but examination of a formalin-fixed brain is better for finding subtle abnormalities in cases without a definitive history of seizures (Fig. 17; refs. 11 and 112). The role of epilepsy in a case of bathtub drowning is deduced from the medical history and the toxicological results. Toxicological testing of drowned individuals in bathtubs, who had been prescribed antiepileptic medications, usually show that the drugs were either not detected or present in sub-therapeutic concentrations (30,132,176). Even individuals with therapeutic levels can drown (132).

Fig. 16. Seizure. (A) Laceration (arrowhead), right lateral border of tongue. (B) Coronal sections of tongue. Hemorrhage in muscle (arrowhead) corresponding to laceration.

A fall, alone or in combination with ethanol, leading to fatal craniocerebral trauma or positional asphyxia needs to be considered if the victim is found in a dry tub (176).

Most of the children who drowned in a bathtub in a North Carolina series were 6 mo to 2 yr of age (176). Children of this age have been usually left unattended (Fig. 18; refs. 12, 42, 55, 103, 175, 176, and 180). The median depth of water in one series was 20 cm (8 in.), and the range was 5 cm (2 in.) to 35 cm (14 in. [77]). The victims were mostly under 1 yr of age (77). At this age, a child is able to sit and pull up to stand (55). Leaving an infant in the care of an older sibling is an inadequate substitute for adult supervision. These children are also at risk for scalding injuries (103). Issues arise about the role of siblings or playmates in the drowning (55). The family situation can be a risk factor for nonaccidental injury. Immersion is a form of child abuse and is used to commit murder (Fig. 19; refs. 103, 180, and 181).

13.2. Suicide

Suicide victims are usually more elderly, and there may be a psychiatric history (see Heading 3. and ref. 182). This method may be chosen by an older person if other methods are not feasible because of illness or immobility (182). Evidence of self-

Fig. 17. Woman found slumped over edge of bathtub filled with water. Signs of drowning at autopsy. History of a "fit" about 1 yr prior to death. (A) Abrasions of pelvis indicative of pressure from tub edge (arrows). (B) Formalin-fixed brain. Expansion of right frontal gyrus. Microscopic examination: astrocytoma. (Courtesy of the Canadian Society of Forensic Science Journal).

Fig. 17. Woman found slumped over edge of bathtub filled with water. Signs of drowning at autopsy. History of a "fit" about 1 yr prior to death. (A) Abrasions of pelvis indicative of pressure from tub edge (arrows). (B) Formalin-fixed brain. Expansion of right frontal gyrus. Microscopic examination: astrocytoma. (Courtesy of the Canadian Society of Forensic Science Journal).

inflicted injury may be seen (e.g., wrist slash; see Chapter 7, Subheading 2.1. and ref. 182). Some individuals have weighed themselves down by various means (e.g., bowling balls [182]). A bathroom door locked from the inside is seen only in a minority (174). Alcohol consumption and sedation by medications have been seen in a number of studies; however, a reduced level of consciousness is not necessary for an individual to deliberately submerge in the bathtub (182).

Fig. 18. Drowning of infant determined to be an accident. Scene findings: mother was in a bathtub with child resting on her torso. She fell asleep and, on awakening, discovered the child submerged. She panicked and sought help. (A) Note the cleanser can on the floor. Cigarette ash was on the floor. The mother did not remember knocking over the ashtray. (B) A frantic call for help.

Fig. 18. Drowning of infant determined to be an accident. Scene findings: mother was in a bathtub with child resting on her torso. She fell asleep and, on awakening, discovered the child submerged. She panicked and sought help. (A) Note the cleanser can on the floor. Cigarette ash was on the floor. The mother did not remember knocking over the ashtray. (B) A frantic call for help.

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