REPORT AND OPINION IN THE CASE OF LI WANGYANG (DECEASED)

Stephen Cordner MB BS FRCPA FRCPath Professor of Forensic Medicine, Monash University Director, Victorian Institute of Forensic Medicine Sameera Gunawardena MB BS DLM MD DMJ Registrar in Forensic Pathology, Victorian Institute of Forensic Medicine

CONTENTS
BACKGROUND MATERIALS CIRCUMSTANCES List of people involved around the time of death Medical History Events prior to death Photographs Summary of three reports: Part I, Part II, Part III Summary of report: Li Wangyang failed 2 suicide attempts REVIEW OF THE LITERATURE Overview of neck injuries in hanging Soft tissue injuries -Ligature mark -Subcutaneous fat and muscle -vascular injuries Laryngeal injuries Cervical spine injuries THE INCIDENCE OF CERVICAL SPINE INJURIES IN 2454 SUICIDAL HANGINGS EXAMINED AT THE VIFM FROM 2000 2011 UNDERTAKERS FRACTURE, OR ARTEFACTUAL POST MORTEM CERVICAL SPINE FRACTURE HOMICIDAL HANGING TO IMITATE SUICIDE DEATH FROM OTHER CAUSES (EG HOMICIDE) WITH SUBSEQUENT HANGING TO IMITATE SUICIDE WHAT ARE THE ISSUES IN THIS CASE? 1. Did this investigation meet the international standard for the investigation of deaths in custody? 1

2. Did this investigation meet the international standard for forensic pathology generally? 3. What is the evidence in favour of suicidal hanging in this case? 4. What is the evidence against suicidal hanging in this case? 5. Did Li Wangyang hang himself?

BACKGROUND: I (SC) was asked by Mr Lee Cheuk Yan, Chairman of the Hong Kong Alliance in support of Patriotic Democratic Movements of China, to review the death investigation findings in this case and to provide an opinion on the death. I asked one of my staff, Dr Sameera Gunawardena, to assist, and therefore this is a report co-authored by us both. However, SC also accepts personal responsibility for its contents and conclusions. MATERIALS: We have had access to the following material provided by Mr Lee Cheuk Yan: 1. Li Wangyang Report Part I Hong Kong China News Agency is entrusted by the Hunan Provincial Public Security Department to release the findings of the investigation into the death of Li Wangyang 2. Li Wangyang Report Part II Joint Investigation Report on Li Wangyang by the Hunan Public Security Bureau Joint Investigation Team 3. Li Wangyang death inquiry report Part III Hunan Public Security Bureau Forensic Opinion Report: 4. Li Wangyang failed 2 suicide attempts By Jia lei (Beijing 13 July): We have also seen three photographs of the death scene (available on the internet) 1. Photograph of the deceased, hanging and being hugged by a woman, presumably the deceaseds sister; 2. Closer up view of the deceaseds head while hanging; 3. View of the back of the deceaseds lower legs and feet with sandals on taken while the deceased is hanging. We have reviewed the literature and undertaken some research into cases of hanging examined at the Victorian Institute of Forensic Medicine.

CIRCUMSTANCES: List of people involved around the time of death: To facilitate reading, the names of those who are mentioned within the report, and their role, are listed below: 1. 2. 3. 4. 5. Li Wangyang (LW) 61 year old male the deceased Li Wangling sister of the deceased Zhao Baozhu brother in law of the deceased Li Lesheng 44 year old male patient in the same room as Li Wangyang Zhang Hejiao 69 year old woman admitted to same room as Li Wangyang on 5 June 6. LuiFengsu 40 year old daughter of Zhang Hejiao 7. Yu Xiangyin 22 year old female hospital nurse 8. Wu Zhuying 64 year old female wife of a patient in another ward 9. Su Heng 28 year old male doctor 10. Wang Xin-e; Wang Shangkun mentioned as being present in the video

Medical History: When first imprisoned in 1989, Li Wangyang was medically assessed. He had hepatitis, hyperthyroidism and poor visual acuity. When imprisoned again in 2001 he had: severe myopia, total loss of hearing in the right ear, left ear can hear only when spoken to at a very short distant loudly, goiter was found hyperthyroidism, thyrotoxic heart disease, secondary bilateral blindness and deafness. (Li Wangyang Report Part 1) Events prior to the death: (These have been extracted mainly from Li Wangyang Report Part II) On 20 May 2011, LW was admitted to the hospital. He was placed in Bed 16 in Ward 16 19 on the 7th floor. This was a 4 bed ward. Bed 16 was next to the door, bed 19 next to the window. On 5 June, two other patients were admitted to ward 16-19: Li Lesheng and Zhang Hejiao. Zhang soon moved to ward 6 9. On the night of 5 6 June, only LW (bed 16) and Li Lesheng (bed 18) were in the ward. At around 22.00 on 5 June, before going to sleep, Li Lesheng saw LW sitting against the wall on his own bed At about 02 55 on 6 June, Li Lesheng woke up and hazily saw LW standing motionless in from of the security window net. Li Lesheng pressed a button to summon assistance. Yu Xiangjin arrived at 02 58. She told Li Yesheng that LW is exercising. It doesnt matter. Li Lesheng was 3

worried enough to leave the ward and slept in a vacant bed in the corridor. At 05 37 Wu Zhuying saw through the open door that LW was standing motionless in front of the window with his back to the door in his ward. A white piece of cloth was dangling behind the back of his head. She told her husband who suggested she mind her own business therefore She did not report this to the doctor At about 06 20, Li Fengsu returned to ward 16 19 for some tissue paper. She saw LW standing in front of the window, facing out, with a white piece of cloth connected to the security net of the window. She realized something was wrong. Yu Xiangyin arrived in the ward at 06 26. Dr Su Heng arrived at 06 28 and confirmed death. Photographs: Photo 1: This shows the deceased looking out the window with his lips and face against the metal security screen. The fingers of his left hand are apparently naturally over a blue cord at chest height. (This assumes that this is indeed LWs hand, and not that of his sister). A dark cloth or item of clothing is hanging on the screen in front of the deceased. There is a white cloth ligature around the left side of the neck sloping upwards under the chin and across the right back of the neck with the knot located in front of the lower right ear. The deceased is wearing a white T-shirt with partially visible writing on the back. A distressed woman is resting her head on the back of his left shoulder. The face is neither congested nor pale. It is the same colour above and below the ligature. The left hand is pale, not congested. Photo 2: This is a closer up view of Photo 1 above. What is possibly an in-canal hearing aid in the right ear is visible. No obvious injuries seen to the right side of the face or to what is visible of the right side of the neck. Photo 3: This is a photo of the feet and lower legs. Both feet have sandals on. The left heel appears to be off the sole of the sandal, whereas the right foot appears to be flat and on the sole of the sandal. There are no injuries to the back of the lower legs. Summary of three reports: Part I Human Provincial Public Security Department confirmed LW died by hanging himself. On 6 June, the Da-xiang sub-office of the Shaoyangshi Public Security Bureau conducted on-scene examination and that of the cadaver surface at the presence of sister of the deceased. On 8 June, the Forensic Medical Appraisal Centre from Zhongshan University was entrusted to conduct autopsy according to the law. Part of internal organs taken for histological examination. Part of the stomach content and cardiovascular blood taken for toxicity analysis. The whole forensic examination was videotaped. 9 June, Li Wangling submitted an application for cremation LW body was cremated. 4

(The investigation) concluded that the rope groove (or rope shaped bruising) on the neck of LW fulfills criterias to be judged as created when he was alive. There was transverse fracture of the C4 vertebrae with bleeding which fulfills criteria for over extension of the head and neck and evidence of axial pulling forces. (Which ageing and osteoporosis were contributing factors as well). No other mechanical injuries could be found over the skin and mucosa of both the oral (mouth) and nasal (nose) cavity, which rules out mechanical injuries and death caused by pressing on the mouth and nose. Toxicology screening showed no abnormalities, which fits with picture of strangulating to death. On 23 June a 5 member team of experts (including Cong Bin, Wanlihua) produced a Consultation Opinion of the Forensic Appraisal Experts which concluded that LW hanged himself. From 19 June to 9 July, the Joint Investigation Team of Hunan Provincial Public Security Department re-examined the evidence, including the scene: Finger print on the security net of the window belonged to LWs right thumb; Dust from the shoeprint left on the white bed cover was from the slipper of LW; The ligature found around the neck came from the bed sheet from LWs own bed.

Video footage showed that only 7 people went in or out of the ward through that corridor between 22.00 hours on 5 June and 06.28 hours on 6 June. These were: medical staff, patients and nursing staff. The Joint Team combined the opinions of the judicial examination report by the Forensic Medical appraisal Centre of Zhongshan University, the Consultative Opinion of the Chinese Forensic Medical Association with their own studies and confirmed that LW killed himself by using the bed sheet of his own bed in the hospital. Summary of three reports: Part II This section comprises a description of the ward, the positions of the bed. The upper end of the knot was hanged to the horizontal bar 217.7 cm up from the floor. It was confirmed that the finger print on the security net of the window belonged to the right thumb of LW. The dusty shoe print extracted from the mattress on Bed fracture19 found next to the window was left by LWs slippers. The ligature around LWs neck came from the bed sheet. When the body was examined at 08.32 on 6 June, the time of death was estimated to be between 01.00 hours and 03.00 hours on 6 June based on the blanchable livor mortis on both lower legs, rigor mortis present in the big joints.

When the body was examined at 17.36 on 6 June at the Dragon Funeral Parlour, the ligature mark was described: There was a hanging groove over the thyroid cartilage with a width of 1.5 cm, from the left side of the neck going downwards and then up to just below the right ear. The total length is 36 cm. There was some sloughing of skin over pressurized area. There was a 1.5 cm x 0.6 cm pressure mark over the left patella and another 1.7 x 0.8 cm pressure mark over the right patella. Both with epidermis intact. There were no other abrasions over the body surface. Mechanical injuries caused by covering of the mouth and nose can therefore be ruled out. No other mechanical injuries could be found over the skin and mucosa of both the oral (mouth) and nasal (nose) cavity, which rules out mechanical injuries and death caused by pressing on the mouth and nose. Toxicology screening showed no abnormalities, which fits with picture of strangulating to death. The autopsy was conducted at 16.26 on 8 June. On 19 June, the Centre of MedicoLegal Expertise of Sun YatSen University concluded that the rope groove on the neck of LW fulfills criteria to be judged as created when he was alive.There is a transverse fracture of the C4 vertebra with bleeding which fulfills criteria for over extension of the head and neck and evidences of axial pulling forces. (Which ageing and osteoporosis are contributing factors as well). No other mechanical injuries can be found on the body surfaces and internal organs. Specialists from the Chinese Forensic Medicine Association went to Shaoyang on the 21st and 22nd of June to have a repeated investigation over Li's cause and nature of death. After detailed understanding over Li's dying process, Concerning the queries on Li's both feet touching the ground and tongue remaining inside ) that, the mouth when he was found dead, it is stated in the ( according to the theory and practice of Forensic Science, mechanisms involved in strangulation to death include suffocation caused by pressure closing the airway, pressure on blood vessels causing diminished blood supply to the brain, pressure on the vagus nerve causing reflexive cessation of heart beats and breathing motions, sudden falling of body during hanging process causing pulling and fracture over the C3 and C4 vertebra and subsequent spinal cord injuries. These mechanisms can cause death alone or synergistically. The tranverse fracture of the C4 vertebrae with bleeding found on Li's body matches the last mechanism listed above, which is also the most objective important evidence for Li's cause of death. (Our emphasis) Summary of three reports: Part III This simply contains excerpts of the above. There is no new information in Part III Summary of report: Li Wangyang failed 2 suicide attempts This report states that LW made two unsuccessful attempts at suicide between 2008 and 2010, demonstrating the presence of suicidal thoughts and preparation. He apparently had attempted suicide by the same method at 2am on

11 December, 2008, and at 2am on 7 August 2010 he made an attempt by using a shoe string. The report summarises mechanisms of death in hanging, and also states, in relation to the fractured cervical spine: Other contributing factors to the fracture of the vertebra were his long term insomnia, other illnesses, and aging that gradually brought about osteoporosis. There is also discussion explaining that a pale face does not exclude hanging. In a paragraph headed: The fracture of the vertebra confirmed suicide, the report states: He fell suddenly after tying the noose. The bed and the mattress were 52 cm from the ground. He measured roughly 60kg. One can imagine how big the stretching force could be on the neck with the free fall of such a mass. This is a violent shock, and hence the fracture on his 4th vertebra. There was also obvious bleeding. It is also stated, in relation to the question of whether cremation of the deceased would affect review of the case, that according to the forensic profession, review of a case would not be affected as long as samples were sufficiently extracted in the autopsy. REVIEW OF THE LITERATURE Overview of neck injuries in hanging The definition of hanging is compression of the neck by a ligature where the compressive force is from the weight of the body. Hanging is most commonly suicidal, but it can be accidental, occasionally homicidal, and in some cases, the result of judicial execution. In addition, sometimes people who die from other causes (e.g. homicide) are, after death, put into a hanging position by others to mimic suicidal hanging. In the mind of the average person, there is confusion between how death occurs in judicial hanging and how death occurs in domestic suicidal hanging. In the former, the mechanism of death is intended to be cervical spine fracture and/or dislocation with subsequent damage to the high spinal cord leading to death. The average person thinks this is what also happens in domestic suicidal hangings. However, this is not the case. In domestic suicidal hanging, cervical spine injury is very rare there is usually little or no drop to cause spinal fracture. Often the deceased is standing or even kneeling and the suspension point is relatively low. Even when there is a short drop (for example, the victim steps off a chair or low ladder), cervical spine injury is rare. In the usual domestic suicidal hanging, the mechanism of death involves the structures at the front of the neck and is one or more of: Stimulation of the vagus nerve slowing and/or stopping the heart. Compression of one or both carotid arteries which take blood to the brain. Compression of neck veins impeding the flow of blood back to the heart from the brain. 7

Obstruction to the airway (or wind-pipe) impairing the ability to breathe.

It is usually not possible in any particular case of domestic suicidal hanging to say what the precise mechanism was. It is usually regarded as a combination of the above in unknown proportions. Hangings have broadly been classified into two types: Complete or total where the whole body is suspended and the feet are off the floor/ground Incomplete or partial where only part of the body is suspended and the feet are or even more of the body is - on the floor/ground. The minimum weight needed for occlusion of neck structures has been experimentally determined 1 and a weight of 5-10kg is regarded as sufficient to completely occlude all the neck structures. Therefore the weight of the head alone may be sufficient to cause death in hanging. This is supported by examples of successful hangings from very low suspension points.

There are non specific signs associated with hanging: petechial haemorrhages, facial congestion and protrusion of the tongue. The occurrence of these is variable and their presence or absence in particular cases is not usually determinative of anything. Internal neck injuries seen in hanging can be broadly grouped as: Soft tissue injuries, including skin, subcutaneous fat, muscles, tongue, prevertebral tissues Vascular injuries: carotid arteries Laryngeal injuries: hyoid bone, thyroid cartilage, cricoid cartilage Cervical spine injuries The factors that influence the presence or absence of injuries have been reported in literature and include, The type of hanging o The degree of suspension: total/partial (as described above) o The length of any drop o The type of knot: sliding/fixed/looped o The position of the knot: sub-mental beneath the chin/sub auricular beneath the ear/back of the neck Characteristics of the ligature o The nature of the ligature material Rough/soft/flexible o The width of the ligature narrow/broad Characteristics of the deceased o Age o Weight

Soft tissue injuries Ligature mark: A broad soft ligature may leave little mark on the skin, especially if the deceased is found early and the ligature removed. Narrow and firm ligatures, especially if the hanging is found after some time, may leave a leathery parchment like abrasion on the skin, which is essentially a consequence of compression and drying of the epidermis of the skin. Actual bruising of the skin is very uncommon. There is general agreement that it is often not possible to distinguish between a genuine suicidal hanging, and the hanging of a body within one or two hours of death based on the macroscopic and microscopic evaluation of the injuries to the neck, including the ligature mark. In other words, the macroscopic and microscopic appearances of the ligature mark in both circumstances (ante mortem and post mortem hanging), all other things being equal, may be the same. A recent paper from Italy and Spain2 has begun the search (in the English language literature at least) for reliable immuno-histochemical markers to help distinguish between hanging/ligature marks created before or after death. Subcutaneous fat and muscle: Occasionally there is haemorrhage in the sternocleidomastoid muscles. Haemorrhage of a mild or moderate degree may also be seen in association with injuries to the laryngeal structures (see below) but may also be seen as isolated injuries. The presence of these injuries might be thought to be more likely in total suspensions of heavier subjects due to greater traction forces. Polson Gee and Knight give a range of 2 12% regarding the presence of neck muscle injury in hanging3. In Di Maio4 out of 83 cases 27 (32.5%) had muscle haemorrhages. In a series by Samarasekara and Cooke5, isolated muscle haemorrhages were seen in 9 out of 136 partial hangings (6.6%) and 5 out of 97 complete hangings (5.1%), the latter being contrary to the comment above. More recent studies have shown no statistically significant correlation between muscle injury and type of hanging6,7. Vascular injuries Vascular injuries are also rare in hanging and are usually seen as transverse intimal tears and/or perivascular haematomas. According to Vanezis8 these are mostly caused by traction and not direct pressure on the vessels. A summary of the vascular injuries found in studies is included in Table 2. The rarity may be exacerbated by a failure to routinely inspect the interior of the carotid arteries. Laryngeal injuries Different studies have shown varying results. Summarized below in Table 1 are some of the studies.

Table 1: Summary of laryngeal fractures from different studies found in forensic literature Number of cases with fracture(s) of thyroid cartilage 36 (34.3%) 71 (30%) 45-Right (25.7%) 48-Left (27.4%) 21(6.8%) 107 (46.9%) 9 (10.8%) 45 (22%) 43 (18.6%) Number of cases Number of cases with fracture(s) of hyoid bone with fractures of both the thyroid cartilage and hyoid bone 28 (26.7%) 16 (7% ) 19-Right (10.8%) 21-Left (12%) 10 (3.2%) 110 (48.2%) 0 3(1%) 6 (2.6%) 17 (16%) 19(8%) 5 (2.8%) N/A 9.1% 0 10(5%) 5 (2.1%)

Total Study number of cases

9

Davison & Marshall

105 233 175 307 228 83 206 231

Samarasekara& Cooke5 Nicolic et al6 Feigin21 Suarez-Penaranda7 Di Maio4 Clement et al Godin et al

11 10

Betz &Eisenmenger

12

109

Not differentiated 73 (66.9%) had at least one fracture of the thyroid cartilage or the hyoid bone or both

N/A

N/A Not Available. The considerable differences between studies reflects a number of things: different methodologies some studies are retrospective, some are prospective; different levels of dissection; local variations in methods of hanging; different populations in terms of age and sex.

Cervical spine injuries The presence of cervical spine injuries in hanging has generally been regarded as due to a significant drop during suspension. The sudden jerk on the ligature causes severe traction on and/or hyperextension of the neck. The injuries identified have included cervical spine dislocation and the typical hangmans fracture fracture dislocation of C2-C3 (that is, the second and third cervical vertebrae). Cervical spine injuries and upper spinal cord injury have conventionally being regarded as the mechanism of death in judicial hangings. In one study of 6 cases of skeletal remains of judicially hanged prisoners the authors found cervical fractures in all the cases (100%)13. Based on appearances during exhumation the authors concluded that there were abnormal rotations in the cervical vertebrae 10

in five of these six cases which were interpreted as possible dislocations in addition to these fractures. In a similar study of 34 cases of judicial hanging14, cervical spine fractures were identified from the skeletal remains of 7 cases (19%). Unlike the previous study, there was no evaluation in the exhumation process of the existence of dislocation. The postmortem examination records from 21 of these cases were also reviewed and showed that there were at least 11 persons who were reported to have died from cervical dislocation, cervical fracture or a combination of both. The presence of cervical fracture or dislocation had not been documented in the post mortem reports of 2 of the above 7 cases.In this study the average drop distance for the fractured group was 73 inches. The average drop for the non-fractured group was 83 inches. Therefore a positive correlation between drop distance and cervical fractures could not be established in these cases. In these cases there was no information about how the ligature, and especially the knot, was positioned. Individual case reports on two instances of more recent judicial hangings with postmortem CT findings were found15,16. One had only cervical spine ligamentous damage, and the other had a complete transection of the spinal cord with the typical hangmans fracture. Forensic textbooks reiterate the fact that cervical spine injury in non-judicial hangings is a rare phenomenon4,17,18 but may occur with a drop, or where individuals have osteoporotic bone19. Most reported cases of domestic hangings with cervical spine fracture have been in circumstances where the individual has been of significant weight or where there has been a significant drop in the hanging. In Di Maio4 out of 83 cases, one fractured cervical spine was found in an obese female with arthritic changes in the cervical spine who stepped off a ladder and was fully suspended. Knight17 commented on finding a fractured cervical spine in a heavily built soldier who hanged himself by a rope secured to an overhead cistern (of unknown height from the ground) and jumping off the lavatory seat. Cooke20 reported on a case of a 31 year old man who was found fully suspended from the bough of a tree with his feet 2 metres above the ground. He had a fractured 2nd cervical vertebra along with severe internal injuries to other neck structures. Review of journal articles showed both retrospective and prospective studies of hangings where a few cases of cervical spine fracture had been identified (Table 2). An analysis of 307 accidental and suicidal hangings by Feigin showed cervical injuries in 3 cases21. The locations of these injuries were recorded as C1-2, C3-4 and C5-6. Hemorrhage was identified around these fractures and only one (C5-6) case had associated laryngeal injury. The details regarding the circumstances of hanging were limited in these three cases. The authors had stated that there was no possibility of a substantial fall meaning, we believe, that a significant drop could not have occurred during the hanging. Another series by Suarez-Penaranda et al7 showed cervical fractures in 3.6% (8 out of 228) and stated that there was no statistical association between the occurrence of cervical fractures and the type of hanging, 11

gender or body weight. Interestingly, perhaps even remarkably, everyone of the 8 cases was said to have fractured at the same location: the second cervical vertebra. It was not clear how these fractures were detected or whether they were confirmed. There was no reference to other associated injuries or the circumstances of these hangings. In another study of 175 cases anterior subluxation of C6-C7 vertebrae was detected in 3 cases. Again the circumstances and associated injuries were not reported.

All these studies were retrospective studies where conclusions about cervical fractures were not the primary focus. In a prospective study of 233 hangings by Samarasekara and Cooke5 there was one cervical spine injury noted which was associated with transection of the larynx and a lengthy drop. A summary of the results of these studies with respect to laryngeal and cervical fractures is given in Table 2.

Hangmans Fracture The basis of the hangmans fracture has been described in the article by Schneider and Livingstone22 and typically involves a transverse fracture across the pedicles and vertebral body of C2 as a result of forces acting on the fixed C1 and C2(atlanto-occipital complex) and the mobile C3 vertebrae. This separates the odontoid peg from the lower half of the vertebral body of C2. This type of fracture is not exclusive to hanging and is more often seen in victims of motor vehicle trauma. As seen from the studies mentioned above, similar fractures have been identified in some of the skeletal remains of judicial hangings but it is clear that there has not been any consistency in their occurrence and no clear relationship could be established between the method of hanging and cervical fractures even in judicial hangings. It is important to note however that in these studies, the fractures have been predominantly identified in the upper cervical vertebrae, the majority being the 2nd and 3rd cervical vertebrae (C2 and C3). In non judicial hangings the incidence of cervical vertebral fractures appears to be much less with the highest reported in these case studies being 8 from 228(3.5%) by Suarez-Penaranda7. We are concerned about this study as each of the 8 fractures was reported as involving the second cervical vertebra. Fractured cervical spine was not a central focus of the study, which was also a retrospective one. How the fractures were diagnosed was not described. One study (Feigin)21 reported a fracture of C3-4 and fracture or dislocation of C5-6/6-7. Nikolic6 reported anterior subluxation (which we understand to mean some degree of dislocation) of C6-7 in three cases.

12

13

TABLE 2: Summary of laryngeal, vascular and cervical spine injuries from a broad literature review of hanging Study Cases 1-judicial (Sub auricular knot) 1-judicial (Knot placed sub auricular but slipped to sub aural) 6 judicial (sub aural) Thyroid cartilage Hyoid bone Fracture left wing of hyoid Vascular vertebral or carotid artery Bilateral small vertebral tearswith subarachnoid haemorrhage Bilateral vertebral lacerations with subarachnoid haemorrhage Bilateral carotid intimal tears. Cervical Spine Incomplete tears of intervertebral ligaments at C2-C3 and C5-C6 levels with partial mobility of C3-C4-C5 block of vertebrae. fracture separation of C2 on C3 with complete transection of spinal cord C1 fractured in 2 cases C2 fractured in 4 cases C3 fractured in 2 cases C5 fractured in 1 case Upper cervical dislocations seen in 5 cases C2 fractured in 6 cases C3 fractured in 1 case with congenitally abnormal vertebra Anterior subluxation of C6-C7 in 3 cases 1case (site not mentioned, associated with transection of larynx) C1-2fracture C3-4fracture C5-6/6-7 unclear if fracture or dislocation C2 fractured in 8 cases C2 fracture in 1 case 1 (site not mentioned) 1 (site not mentioned) N/A N/A N/A

Reay et al15

Midline fracture

Hartshorne

16

fractured

fractured

Spence et al13

N/A

Fractures in 2 cases

N/A

James & Nasmyth-Jones14 Nicolic et al6 Samarasekara & Cooke5 Feigin21 Suarez-Penaranda7 Cooke
20

34-judicial (different knot positions) 175 233 307 228 4 83 1 206 231 109

N/A 45-Right side 48-Left 90 21 107 1 9 N/A 55 43 (18.6%)

N/A 19-Right 21-Left 35 10 110 1 0 N/A 13 6 (2.6%)

N/A 19-Right 13-Left 13 N/A 9.1% 2 N/A N/A N/A 5 N/A

Di Maio4 Knight17 Clement et al10 Godin et al11 Betz & Eisenmenger12

Not differentiated; 73 cases with at least 1fracture of thyroid , hyoid or both

N/A Not Available or Not Applicable: Authors underlined are those who have reported on judicial hangings.

14

THE INCIDENCE OF CERVICAL SPINE INJURY IN 2454 HANGINGS EXAMINED AT THE VICTORIAN INSTITUTE OF FORENSIC MEDICINE FROM 2000-2011. A retrospective search was done through the National Coronial Information System (NCIS) for cases of hangings of all intents in Victoria, where the investigation had been completed, between 2000-2011, where cervical spine injuries had been identified at autopsy. The search criteria were as follows Aggregate number of all hangings in Victoria between July 2000 and Dec 2011 inclusive. o Age Range o Gender o Closed cases Hangings with cervical spine fracture A) Searched autopsy reports for all Victorian completed cases where the cause of death was hanging for the following terms: 1. "Undertaker" 2. "Cervical Spine Fracture" 3. "Fractured Cervical Spine" 4. "Fracture of the Cervical Spine" 5. "Fracture of Cervical Spine" 6. "Fractured Atlas" 7. "Fractured Axis" 8. "Dislocation" B) Searched autopsy reports for all Victorian completed cases for the term "fracture" which was not preceded by "no". C) Manually reviewed 25 words on either side of the term "fracture" in these cases The total number of hanging cases during this period was 2454, of which 2005 (81.7%) were male and 449 (18.3%) were female.

Table 3 - All Victorian completed cases of hanging (all intents**): July 2000 to Dec 2011 Gender/Age of Deceased (Years) Male Female Total 0-19 114 48 162 20-39 863 205 1,068 40-59 716 139 855 60-79 260 42 302 80-99 52 15 67 100+ 0 0 0 Total 2,005 449 2,454

** suicide, accident or homicide. The overwhelming majority would of course be suicide. 15

Seven cases were identified where the autopsy report had identified some form of bony cervical spine injury. All these seven cases were deemed to be suicides. The deceased persons were all male, and their ages ranged from 35-81 years, with four being between 40-50 years. The circumstances of death of these seven cases were reviewed based on the autopsy report and the Victoria Police Death Report Form 83. Information regarding the type of hanging, the ligature and knot were not available in some cases. The internal injuries were compared with the available information on the circumstances of hanging. In six of the seven cases, the circumstances of hanging were likely to have been associated with a drop and/or complete suspension. The single exception was the case of an 81 year old man who was found hanging in a seated position inside a wardrobe with a belt around his neck. The railing on the ceiling of the wardrobe was found to be broken. It seems that the person had hung himself on this railing which has broken and the deceased, at an unknown time after the suspension, has fallen. He had no fractures of his laryngeal skeleton and no vascular injuries. Examination of the cervical spine showed a fracture of C7 vertebrae with haemorrhage. No further description of these was provided. The possibility of this fracture being a postmortem artefactual fracture (undertakers fracture) cannot be excluded (see discussion below). In four of the seven cases the fracture or dislocation involved the upper cervical vertebrae mainly C2. Three of these four cases were associated with significant injuries to the laryngeal skeleton. The exception was a case of a 41 year old male who had hanged himself from a tree but was immediately found and resuscitated. He died two days later in hospital and the autopsy report records a fracture dislocation of the C2 vertebra, with haemorrhage into soft tissues around the laryngeal region and no fractures of the thyroid cartilage or hyoid bone. In the remaining three of the seven cases (one of which, the 81 year old man, has already been described above) neither fractures of the hyoid bone nor thyroid cartilage were seen,and nor were vascular injuries seen. In one case there was fracture and dislocation of the C6-C7 vertebrae which was associated with a significant amount of spinal epidural haemorrhage. There was also prevertebral haemorrhage over the upper cervical spine with no fractures. The circumstances were of a 40 year old man who had apparently hung himself with a neck tie from a ceiling beam, meaning that there was probably a relatively short drop, if any, but complete suspension (however briefly). However he was found lying on the ground as the neck tie had apparently broken. A ladder was adjacent which he had probably climbed to gain access to the ceiling beam. Another interesting finding in this case was that his hands were also loosely tied behind his back with another neck tie. The events leading up to the death were suggestive of causing the deceased some emotional stress and the case was deemed a suicide. The pathologist commented on the possibility of the fracture being related to postmortem artefactual damage or as a consequence of the fall.

16

The last case was of a 65 year old male who hanged himself from a ceiling beam in a shed. Fracture dislocations involving intervertebral discs of C3-C4 and C5-C6 were noted. The pathologist had commented on the presence of little haemorrhage at the margins of the dislocation. A summary of the above findings is given in Table 4. After review of these findings the following conclusions emerge. 1. Cervical spine injuries are rare in hangings. The incidence in our own study was 7 out of 2454 or approximately 3 per 1000 hangings. This could be an over estimate of the frequency of cervical spine injury due to hanging because of the possibility of falling (during the act of hanging, or some time after) or other post mortem artifact (for example undertakers fracture) complicating the assessment. 2. The cervical spine injuries in these 7 cases were: fractured C7; fracture dislocation C2-3; fractured C2-3; fracture dislocation C2; fractured C2; fractured C6-7; fracture dislocation C3-4, C5-6. 3. As a general rule and based on this small sample, it seems cervical spine fracture/dislocation in hanging: a. occurs when there is a drop and/or full suspension. b. is sometimesassociated with hyoid bone/thyroid cartilage injuries and vascular injuries. 4. There was one case of hanging where there was a cervical spine fracture and probably no significant drop and probably no full suspension. This was a case of an 81 year old man who fractured his C7. Post mortem artifact in this case (or any of the other cases), such as undertakers fracture, cannot be excluded.

UNDERTAKERS FRACTURE OR POST MORTEM ARTEFACTUAL CERVICAL SPINE FRACTURE An issue that needs to be addressed is the possibility of postmortem fracture (notably undertakers fracture) which may have confounded all the studies mentioned above, including our own. It is known that postmortem handling of the body can create artefactual damage to the cervical spine, particularly in older people. For example, reference to these fractures can be found in the article by Camps and Hunt23 which mentions Postmortem fractures of cervical spine are not uncommon and may be caused by forcible laying out, by violence in moving the body and other unduly rough manipulation of the head, especially in forced flexion in reflecting the scalp. These fractures are usually transverse and related to the intervertebral discs between C4 and C5 or C5 and 6. A small extravasation of blood into the prevertebral fascia related to these fractures may also occur as a postmortem artifact. They are especially liable to occur when ankylosis is present

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From our own observation, it is likely that some such fractures occur during moving the deceased. There are many ways in which a deceased person can be moved. When two people are used to move a deceased: one may stand at the head end and put his hands under the shoulders of the deceased, and the other may stand at the feet end and hold on to the legs. As the body is lifted, perhaps quite sharply or suddenly, the head falls back hyperextending the cervical spine. Especially if there is a degree of ankylosis/spondylosis, in some cases this method of lifting will cause cervical spine injury. When associated with some prevertebral bleeding, it may present some difficulty, and not only to the inexperienced pathologist, in distinguishing the post mortem fracture from an ante-mortem injury.

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TABLE 4- Summary of cases where cervical spine injury was identified in 7 out of 2454 suicidal hangings in Victoria from 2000-2011 CASE Age Sex Brief Circumstances Found hanging in seated position inside a wardrobe with a belt. Railing broken. Hanging from pedestrian overpass (1m above ground) Laryngeal injuries Vascular Cervical Spine

81

None (only petechiae)

None

Fracture of C7 with haemorrhage

35

Transverse rupture and separation with haemorrhage fracture hyoid mid part and both cornua with minimal bruising fracture both superior thyroid cornua Transection of larynx at supraglottic region

None

Unstable fracture dislocation of C2/C3 with haemorrhage

40

Hanging from tree(?6m above ground)

Transection of common carotid arteries.

Transverse fracture (with diastasis) to the C2/3 intervertebral space

41

Hanged from tree immediately cut down died in hospital 2 days later Hanging from bridge apparently jumped off

Haemorrhage only fracture B/L thyroid cornuaminimal haemorrhage fracture right hyoid cornua no haemorrhage

None

C2 fracture dislocation

E 49 m

N/A

fracture C2 with haemorrhage fracture dislocation C6-C7 with extensive epidural haemorrhage (given in comments as possible undertakers fracture) fracture dislocations of intervertebral discs of C3-C4 and C5-C6. Little haemorrhage at the margin of the dislocation.

40

Suggestion of hanging from ceiling beam with a neck tie. Hyoid &thyroid intact. Found fallen. Ladder nearby. Hanging from beam in shed. (Ladder nearby.) None

N/A

65

None

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HOMICIDAL HANGING TO IMITATE SUICIDE This is very rare. For obvious reasons, it is difficult to hang a conscious person against their will. There are two ways of hanging a conscious person against their will: either overcome the will to resist (for example by threats or drugs the latter rendering the victim stuporose or incapable of exercising their will), or overcome the resistance by force. With the exception of threats, the other means of homicidal hanging will often be detected by a thorough autopsy. DEATH FROM OTHER CAUSES (EG HOMICIDE) WITH SUBSEQUENT HANGING TO IMITATE SUICIDE That this occurs from time to time is without doubt. The cause of the death prior to the deceased being placed in the hanging position is usually apparent at the autopsy (eg head injury). Difficulties arise when the cause of death is due to homicidal ligature strangulation, and then the deceased is placed in the hanging position, perhaps with the same ligature. COMMENT: We think that, if we were to have a conversation with the specialists referred to in this case, there would be general agreement about the introductory material set out above. WHAT ARE THE ISSUES IN THIS CASE: 1. Did this investigation meet international standards for forensic pathology 2. Did this investigation meet international standards for investigation of a death in custody? 3. What is the evidence in favour of hanging? 4. What is the evidence against hanging? 5. Did LW hang himself?

1. Did this investigation meet the international standard for the investigation of deaths in custody?
The international standard for the investigation of deaths in custody is the United Nations Manual on the effective prevention and investigation of extra legal, arbitrary and summary executions24 which, in Part IV of the Manual, contains a Model Autopsy Protocol: Elements of this protocol include: 1. Scene Investigation: a. photograph the body as it is found and after it has been removed 1. if the decedent was hospitalized before death obtain...any x-rays, and review and summarize hospital records 20

2. Autopsy: c. adequate photographs are crucial for thorough documentation of autopsy findings. i. photographs should be in colour, in focus, adequately illuminated and taken by a professional good quality camera ii. serial photographs reflecting the course of the external examination must be included. Photograph the body prior to and following undressing, washing, or cleaning and shaving iii. supplement close up photographs with distant and/or immediate range photographs to permit orientation and identification of the close up photographs iv. photographs should be comprehensive in scope and must confirm the presence of all demonstrable signs of injury or disease commented upon in the autopsy report. d. Radiograph the body before it is removed from its pouch or wrappings. ii. Document any skeletal system injury by x-ray e. The external examination .is in most cases the most important portion of the autopsy; i. Photograph all surfaces 100% of the body area.. ii. Photograph all injuries, taking two colour pictures of each.. viii. Examine the face and note if it is cyanotic or if petechiae are present;.note any petechiae in the upper or lower eyelids.. xix. The length of the back, the buttocks and extremities including wrists and ankles must be systematically incised to look for deep injuries.. h. The internal examination xi. In cases in which spinal injury is suspected, dissect and describe the spinal cord. Examine the cervical spine anteriorly and note any haemorrhage in the paravertebral muscles. The posterior approach is best for evaluating high cervical injuries. Open the spinal canal and remove the spinal cord. Make transverse sections every 0.5 cm and note any abnormalities. k. The written report.should be given to the appropriate authorities and to the deceaseds family. Based on the information available to us, it cannot be said that the investigation has met international standards for investigating a death in custody. It may be that the authorities indeed possess a number, or even all, of the elements which are missing, which if they were made available, would enable a full and independent assessment. The elements needed as a minimum, based on the requirements of the Model Autopsy Protocol contained within the UN Manual mentioned above, in our view are: 21

 Full set of photographs of the scene of the death Full set of colour photographs adequately documenting all the positive and negative autopsy findings (as set out in the Model Autopsy Protocol) X-ray of the skeletal injury/ies Copy of the full autopsy report, including details of the toxicological analysis, histological assessment, and any other special testing (eg leading to conclusions that the ligature mark around the neck occurred during life). The material currently available does not constitute a full autopsy report as it does not contain many, let alone all, of the elements set out in the UN document.

Conclusion: If any of the required material exists (full set of photographs of the scene, full set of photographs of the autopsy, x-rays of the skeletal injury/ies, copy of the full autopsy report), its main purpose is to allow an independent assessment to validate, or otherwise, the conclusion of the specialists that the authorities are relying on. This material should be made available to the family or their authorized representatives. If the material is not made available to the family, or their authorized representatives, for independent scrutiny then the investigation has not met the international standard for the investigation of a death in custody. If the material does not exist, then the investigation has not met the international standard for the investigation of a death in custody.

2. Did this investigation meet the international standard for forensic pathology?
If there is a single fundamental principle underpinning the conduct of forensic investigations, including forensic pathology, it is that whatever investigation is undertaken must be undertaken in such a way that it is reviewable. In other words the investigation must be done in such a way that another expert, at another time, can review the findings independently and come to his or her own conclusions. Such reviewability underpins the credibility of the original investigation. This principle underlies the heavy emphasis placed on photography in the United Nations Manual on the Effective Prevention and Investigation of Extra-Legal, Arbitrary and Summary Executions, 1989. This principle of reviewability is also explicit in the following excerpt from a WHO published document, Ethical Practice in Laboratory Medicine and Forensic Pathology:

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It is important to appreciate, at the outset, the aims of the forensic autopsy. The aims of this part of a death investigation are:25 i) To discover, describe, and record all the pathological processes present in the deceased and, where necessary, the identifying characteristics of the deceased. ii) With knowledge of the medical history and circumstances of the death, to come to conclusions about the cause of death, factors contributing to death, and, where necessary, the identity of the deceased. iii) In situations where the circumstances of death are unknown or in question, to apply the autopsy findings and conclusions to the reconstruction of those circumstances. This will, on occasions, involve attendance at the scene of death, preferably with the body in situ. iv) To record the positive, and relevant negative, observations and findings in such a way as to enable another forensic pathologist at another time to independently come to his or her own conclusions about the case. As forensic pathology is essentially a visual exercise, this involves a dependence on good quality, and preferably colour, photographs. Conclusion: As mentioned above, any existing detailed autopsy report (including access to the histology slides and the detailed results of the toxicological analysis) and any existing photographs and/or video recordings of the autopsy, have not been made available, so there is no evidence that enables us to say that the first aim of the forensic autopsy, as set out above, has been met. For the same reason there is no evidence that the fourth aim above has been met. We have not been put in a position to independently review the findings of the forensic pathology investigation of this case. If any or all of these materials do not exist, or do exist but are not made available for independent expert review, then the forensic pathology investigation of this death has not met the international standard.

3. What is the evidence in favour of suicidal hanging in this case?

The following discussion is severely handicapped by the absence for review of the primary materials (full set of photographs of the scene, full set of photographs of the autopsy, autopsy report, histology, toxicology report), if they exist. According to the document LW failed two suicide attempts, review of the case would not be affected as long as samples were sufficiently extracted in the autopsy. This implies that some, at least, of the relevant materials do exist. If so, they should be made available for review. The discussion that follows is therefore based on the material in the four reports outlined at the beginning of this report, and is not based on reviewable material made available for evaluation.

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The specialists from the Chinese Forensic Medical Association concluded that the main evidence in favour of hanging was as follows: 3.1: The tranverse fracture of the C4 vertebrae with bleeding found on Li's body ..is also the most objective important evidence for Li's cause of death. In other words, the specialists concluded that the presence of a broken neck was the most important objective evidence that LW died by hanging. The presence of bleeding is the evidence relied upon to conclude that the broken neck occurred while LW was alive. The absence of drugs or other injuries is relied upon as evidence that he was not homicidally hanged, or killed in some other way and then placed in a hanging position. As indicated above in the introductory discussion, fractured cervical spine in suicidal hanging is very rare. It can occur but usually there is an obvious drop or the deceased is fully suspended. In this case, the specialists believe there has been a drop, but see comments below. The deceased in this case is not quite fully suspended. The specialists state that LW had osteoporosis. Osteoporosis is thinning of the bones making them more vulnerable to fracture. We cannot comment on whether this is true or not as we have not been provided with any material to support such a claim. If LW did have osteoporosis, or some pre-existing cervical spine disease, then we accept that this would mean that if LW did hang himself in the way suggested by the specialists, this would increase the chance of a fracture occurring during the process of hanging. It would also increase the chance of a fracture occurring during the moving of the body after death. The specialists who conducted the autopsy also: 3.2 concluded that the rope groove on the neck of LW fulfills criteria to be judged as created when he was alive. We have no basis, no material available to us, which enables us to evaluate this claim. There is no photograph of the ligature mark as seen at the autopsy, there is nothing present in any description of the mark on the neck that could form the basis of this conclusion, there is no description of any histological evaluation of the mark, there is no description of any immune-histochemical evaluation of the mark, there is no histophotograph. The specialists are reported as having made a conclusion the truth of which requires evidence. We would like to see the evidence which underlies this conclusion. If this evidence is not made available, then obviously we are not able to support the conclusion.

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3.3.Dust from the shoeprint left on the white bed cover was from the slipper of LW. As indicated in the report LW failed two suicide attempts the specialists think that LW jumped from the bed, thus increasing the chances of causing the fractured cervical spine (or broken neck). If LW jumped from the bed, it is interesting that his foot wear remains as it does on his feet very neatly, both sandals at right angles to the wall. One could easily imagine the footwear becoming dislodged during such jumping from the bed and finishing up separated from the feet. If he did jump from the bed, this might have caused visible surface or superficial injury to the knees or other parts of the legs as they impacted with some force against the wall beneath the window, and injury to the face as it impacted with the iron grill of the window. No such injury is mentioned. Indeed, the complete absence of any other injury is emphasized. We cannot comment on whether or not such injury is or is not present as the autopsy photographs, if they exist, and if they include the face and legs, are not available to us for review. What can be seen of the face in the publicly available photographs shows no obvious injury. As noted in the background materials, where there has been a drop, a number of such cases also have injury to the structures of the front of the neck. In this case, no such injury was present. If osteoporosis was present, this would also affect the hyoid bone, and this was not fractured, apparently, in this case. 3.4 The fingerprint. Since LW has occupied the hospital ward where he was found dead for some considerable time, it would seem unwise to place much weight on the presence and location of a fingerprint as supporting a conclusion of suicidal hanging. 3.5 The video recording of people entering and leaving LWs ward on the night of his death Independent evaluation of this important evidence is, obviously, central to support or counter the claim that only those people named entered and left the ward, and that all had good reason to enter the ward as they did.

4. What is the evidence against hanging?

It is true that in suicidal hanging there may be little more than the ligature mark around the neck. At autopsy, the absence of other injury, plus an assessment of the overall circumstances is often all that exists to lead one to the conclusion that the death was due to suicidal hanging. In this case there is also the fractured cervical spine. (We cannot independently verify the existence of the fracture because we have not had access to the post mortem photographs, or post mortem x-rays, if they exist). The alternative explanations for the fracture are 25

i) that it occurred after death, perhaps during the removal of the body from the scene. The specialists would probably say that the degree of haemorrhage apparently associated with the fracture means that it occurred in life. (We cannot independently assess any haemorrhage because we have not had access to the post mortem photographs, if they exist, or the actual autopsy report). If the fracture occurred after death, and there were no other injuries present on or in the body, and the circumstances are as the authorities say they are, then suicidal hanging would be a reasonable conclusion. we cannot independently reach the conclusion that this is a suicidal hanging because we do not have access to the full set of scene photographs, full set of autopsy photographs, the histology or the autopsy report. ii) That it is the result of assault. All over the world deaths in custody are viewed with suspicion that the authorities may have been involved in causing the death. In this case, the rarity of cervical spine fracture in hanging means that it is reasonable to consider other possibilities for how this death may have occurred. Assault is the obvious other possibility. (An accidental fall could cause a fractured cervical spine. It is difficult but not impossible - to see how this could occur in this case and be followed by hanging). Independently assessing whether or not assault occurred relies entirely on being able to assess the materials which should have been gathered during the investigation, especially the full set of scene and autopsy photographs, the histology and the autopsy report. We can see no injuries in the photographs (publicly available on the internet) of the right side of the face and neck and of the back of the lower half of the lower legs. Unless, and until, we can see the full set of autopsy photographs which show the full external surface of the body of the deceased in reasonable close up, we are not in a position to independently verify the absence of other injuries. The conclusion that there has been no assault is heavily reliant upon the assertions of the specialists as set out in the reports and cannot at this stage be independently verified (except in relation to the right side of the face and the back of the lower legs). Independent verification is a central principle of forensic pathology practice in accordance with international standards.

5. Did LW hang himself?

We are not in a position to fully and independently evaluate whether or not LW hung himself. The material available to evaluate consists of conclusions and assertions. The primary evidence leading to those conclusions should be available in the form of a full set of scene photographs, a full set of autopsy photographs, histology material and the full autopsy report. These materials should be available as a proper record of the investigation, and as material

26

available for independent evaluation by another expert at another time so s/he can come to his or her own conclusion about the case. Having said that, there is nothing in the available three photographs which directly contradicts the information that is in the public domain. The appearances in the photographs are compatible with, or consistent with, the conclusion of suicidal hanging reached by the specialists. But the three photographs are a long way from all the materials we need to make my own firm conclusion that LW hanged himself.

CONCLUDING COMMENT We are prepared to independently evaluate the materials if they become available. We are prepared to do this in accordance with arrangements acceptable to the family, or their representatives. It would be acceptable to us if there was a requirement that, in undertaking the independent evaluation, we maintained the confidentiality of the primary materials and only shared them with the family and/or their representatives. We have not received any fee for this report. No fee was offered. We did not ask for a fee, and we will not be asking for any fee.

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Betz P, Eisenmenger W. Frequency of throat-skeleton fractures in hanging. Am J Forens Med Pathol 1996;17:191-3 Spence MW, Shkrum MJ, Ariss A, Regan J, Craniocervical injuries in judicial hangings: An anthropological analysis of six cases. Am J Forens Med Pathol. 1999;20(4):309-322
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Reay DT, Cohen W, Ames S. Injuries produced by judicial hanging. Am J Forens Med Pathol 1994;3:183-6 Hartshorne NJ, Reay DT, Judicial Hanging: Letter to the editor. Am J Forens Med Pathol 1995;16(1):87 Knight B, Saukko P, Fatal pressure on the neck. In: Knight B, Saukko P editors, Knights Forensic Pathology, 3rd Ed., Arnold publishers, London;2004:368-394 Spitz WU, Asphyxia, In: Spitz WU, Spitz DJ, editors, Spitz and Fishers Medicolegal investigation of death: Guidelines for the application of pathology to crime investigation, 4th ed., Springfield, Il, Charles C Thomas, 2006:783-845 Dolinak D, Matshes E, Hanging and strangulation. In: Dolinak D, Matshes E, Lew E. Forensic Pathology principles and practice. Elsevier Academic Press; 2005:214 Cooke CT, Cadden GA, Hilton JMN. Unusual hanging deaths. Am J Forens Med Pathol. 1988;9(4):277-288
21Feigin 22 20 19 18 17 16

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G, Frequency of neck organ fractures in hanging. Am J ForensPathol, 1999;20(2):128=30

Schneider RC, Livingstone KE, Cane AJE, Hamilton G. Hangmans Fracture of the cervical spine. J Neurosurg 1965;22:141-54 Camps FE, Hunt AC. Pressure on the neck. J Forens Med1959;6(3):116-135 Manual on the Effective Prevention and Investigation of Extra-Legal, Arbitrary and Summary Executions. United Nations. 1989
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See S. Cordner, B. Linehan, M. El Nageh, D. Wells, H. McKelvie, Ethical Practice in Laboratory Medicine and Forensic Pathology, WHO Regional Publications, Eastern Mediterranean Series. WHO Regional Office for the Eastern Mediterranean. Alexandria. Egypt 1999. page 25.

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