1

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

UNDERTAKER’S 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?

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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:

1.1.1.1. 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

2.2.2.2. 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 deceased’s sister;

2. Closer up view of the deceased’s head while hanging;

3. View of the back of the deceased’s 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.

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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. Li Wangyang (LW) – 61 year old male – the deceased

2. Li Wangling – sister of the deceased

3. Zhao Baozhu – brother in law of the deceased

4. Li Lesheng – 44 year old male patient in the same room as Li Wangyang

5. 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 doesn’t matter”. Li Lesheng was

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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 LW’s

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.

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(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 LW’s 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 LW’s

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 LW’s slippers.

The ligature around LW’s 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.

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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 Medico-

Legal 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

the mouth when he was found dead, it is stated in the (諮詢意見書) that,

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

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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.

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• 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, pre-

vertebral 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

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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.

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Table 1: Summary of laryngeal fractures from different studies found in forensic literature

Study

Total

number of

cases

Number of cases

with fracture(s)

of thyroid

cartilage

Number of cases

with fracture(s)

of hyoid bone

Number of cases

with fractures of

both the thyroid

cartilage and

hyoid bone

Davison & Marshall9 105 36 (34.3%) 28 (26.7%) 17 (16%)

Samarasekara& Cooke5

233 71 (30%) 16 (7% ) 19(8%)

Nicolic et al6

175 45-Right (25.7%)

48-Left (27.4%)

19-Right (10.8%)

21-Left (12%) 5 (2.8%)

Feigin21

307 21(6.8%) 10 (3.2%) N/A

Suarez-Penaranda7

228 107 (46.9%) 110 (48.2%) 9.1%

Di Maio4

83 9 (10.8%) 0 0

Clement et al10

206 45 (22%) 3(1%) 10(5%)

Godin et al11

231 43 (18.6%) 6 (2.6%) 5 (2.1%)

Betz &Eisenmenger12

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 “hangman’s

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

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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

hangman’s 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,

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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.

Hangman’s Fracture

The basis of the ‘hangman’s 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.

13

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TABLE 2: Summary of laryngeal, vascular and cervical spine injuries from a broad literature review of hanging

Study Cases Thyroid cartilage Hyoid bone Vascular – vertebral or

carotid artery Cervical Spine

Reay et al15 1-judicial

(Sub auricular knot) Midline fracture

Fracture left wing

of hyoid

Bilateral small vertebral

tearswith subarachnoid

haemorrhage

Incomplete tears of intervertebral ligaments at

C2-C3 and C5-C6 levels with partial mobility of

C3-C4-C5 block of vertebrae.

Hartshorne16

1-judicial

(Knot placed sub

auricular but slipped

to sub aural)

fractured fractured

Bilateral vertebral lacerations

with subarachnoid

haemorrhage

Bilateral carotid intimal tears.

fracture separation of C2 on C3 with complete

transection of spinal cord

Spence et al13 6 –judicial

(sub aural) N/A Fractures in 2 cases N/A

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

James & Nasmyth-Jones14 34-judicial (different

knot positions) N/A N/A N/A

C2 fractured in 6 cases

C3 fractured in 1 case with congenitally

abnormal vertebra

Nicolic et al6

175 45-Right side

48-Left

19-Right

21-Left

19-Right

13-Left Anterior subluxation of C6-C7 in 3 cases

Samarasekara & Cooke5

233 90 35 13 1case (site not mentioned, associated with

transection of larynx)

Feigin21

307 21 10 N/A

C1-2fracture

C3-4fracture

C5-6/6-7 – unclear if fracture or dislocation

Suarez-Penaranda7

228 107 110 9.1% C2 fractured in 8 cases

Cooke20

4 1 1 2 C2 fracture in 1 case

Di Maio4

83 9 0 N/A 1 (site not mentioned)

Knight17

1 N/A N/A N/A 1 (site not mentioned)

Clement et al10

206 55 13 N/A N/A

Godin et al11

231 43 (18.6%) 6 (2.6%) 5 N/A

Betz & Eisenmenger12

109 Not differentiated; 73 cases with at least

1fracture of thyroid , hyoid or both N/A N/A

N/A – Not Available or Not Applicable:

Authors underlined are those who have reported on judicial hangings.

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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) 0-19 20-39 40-59 60-79 80-99 100+ Total

Male 114 863 716 260 52 0 2,005

Female 48 205 139 42 15 0 449

Total 162 1,068 855 302 67 0 2,454

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

suicide.

16

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 (undertaker’s

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.

17

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 “undertaker’s

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.

UNDERTAKER’S FRACTURE OR POST MORTEM ARTEFACTUAL CERVICAL

SPINE FRACTURE

An issue that needs to be addressed is the possibility of postmortem fracture

(notably – undertaker’s 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”

18

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.

19

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 Laryngeal injuries Vascular Cervical Spine

A 81 m

Found hanging in seated

position inside a wardrobe

with a belt. Railing broken.

None (only petechiae) None Fracture of C7 with haemorrhage

B 35 m

Hanging from pedestrian

overpass (1m above

ground)

Transverse rupture and

separation with haemorrhage None

Unstable fracture dislocation of C2/C3 with

haemorrhage

C 40 m Hanging from tree(?6m

above ground)

• fracture hyoid mid part and

both cornua with minimal

bruising

• fracture both superior

thyroid cornua

• Transection of larynx at

supraglottic region

Transection of

common carotid

arteries.

Transverse fracture (with diastasis) to the

C2/3 intervertebral space

D 41 m

Hanged from tree

immediately cut down –

died in hospital 2 days later

Haemorrhage only None C2 fracture dislocation

E 49 m Hanging from bridge –

apparently jumped off

• fracture B/L thyroid cornua-

minimal haemorrhage

• fracture right hyoid

cornua – no haemorrhage

N/A fracture C2 with haemorrhage

F 40 m

Suggestion of hanging from

ceiling beam with a neck tie.

Found fallen. Ladder

nearby.

Hyoid &thyroid intact. N/A

fracture dislocation C6-C7 with extensive

epidural haemorrhage

(given in comments as possible

‘undertaker’s fracture)

G 65 m Hanging from beam in shed.

(Ladder nearby.) None None

fracture dislocations of intervertebral discs

of C3-C4 and C5-C6. Little haemorrhage at

the margin of the dislocation.

20

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 Nation’s “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

21

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 deceased’s 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:

22

• 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:

23

“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.

24

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.

25

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 LW’s 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

26

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

27

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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