Suicidal ligature strangulation: a systematic review of the published literature

To summarize the published forensic pathology evidence base in deaths concluded to be the result of suicidal ligature strangulation, an uncommon entity. Four electronic bibliographic databases Medline Ovid, Embase, Scopus, HEINonline were screened for relevant literature. No date restrictions were applied. All English language case reports or case series were included. Articles were evaluated and key data extracted according to predefined criteria. A total of 1554 references eventually yielded 24 papers with 31 eligible case reports. The location of the deaths and background circumstances and history mirror broadly those of suicide generally. The range of ligature types was diverse. 19/31 cases reported one or more knots present. In the remaining 12 cases, the ligatures did not lend themselves to knots. In only one case were laryngeal fractures reported, but the available material does not justify confidence in that report given the significance of the finding. This systematic review has identified and synthesized the evidence from 31 case reports of suicidal ligature strangulation. A forensic pathologist faced with a possible case can locate it within the spectrum of reported cases and therefore identify its common and distinguishing features. Inherent difficulties for research in forensic pathology mean that case reports are an important source of learning and evidence for the discipline. Opportunities for improvement exist especially in harmonizing terminology and standardizing techniques generally, and in reports of suicidal ligature strangulation in particular.