A scoping review of strangulation and hanging: determining suicide from concealed homicide in equivocal death cases

Abstract

There has been limited investigation on the cross-over between suicide and homicide: when should suicide be considered concealed homicide? A scoping review was undertaken examining hanging and ligature/manual strangulation deaths, including suicides and homicides staged to appear as suicides. Three types of manner of death indicators were identified: scene, decedent and medical. Scene factors suggestive of staging in hanging and strangulation cases include certain aspects of the victim’s hair, jewellery and clothing, evidence of clean-up, and unexplained absence of items. The decedent’s mental illness, previous suicide attempts and psychological distress remain risk indicators, but protective factors warrant consideration. Medical indicators are controversial, especially for fractures. Views that manual strangulation relates solely to hands around the neck are simplistic and fail to account for other lethal manual methods. Hanging cases need to be thoroughly investigated, particularly when a female decedent is discovered by an intimate partner.

Since the mid-1980s there has been a significant increase in the number of suicides by hanging in Australia. Since 1989, hanging has become the most common suicide method for males, and for females from 1997. The rates of suicide by hanging for males has progressed from 5.7 deaths per 100,000 in 1989, to 12.5 in 2019, accounting for almost two thirds (62%) of male suicides. Female hangings have progressed from 1.9 deaths per 100,000 in 1997, to 3.3 in 2019, with half (50.4%) of female suicides being by hanging (Australian Institute of Health and Welfare, 2024). Similar trends have been observed in New Zealand, with hanging the leading cause of death for males and females who suicided in 2013. Medical literature indicates that hanging, or pressure to the neck through the act of hanging, is considered a common method of suicide. This is due to it being relatively painless, typically rendering a person unconscious within 15 seconds (Rahman et al., 2017; Saukko & Knight, 2004).

Alongside suicide trends, over the last 20 years there has been growing acknowledgement of the risk of death when a person is strangled by someone else and the frequency with which these behaviours occur in intimate relationships (Pritchard et al., 2017). Glass et al. (2008) found women who had previously been strangled were 7.48 times more likely to be murdered in an intimate partner femicide (IPF). For female homicide victims in Australia, strangulation is a common cause of death (Miles & Bricknell, 2024). IPFs also regularly involve elements of detection avoidance and concealment (Monckton Smith, 2019). A study of all IPFs in Queensland from 2006 to 2019 found 43% involved some form of detection avoidance by offenders (McLachlan & Ferguson, 2024). In Ferguson’s (2015) study of staged homicides, it was found that 56% involved victims and offenders who were intimate partners. Monckton Smith (2019) discusses concealment of the death as a key feature of IPF, with many IPFs being made to appear as non-suspicious deaths, including suicides. Given the frequency with which strangulation is used in abusive relationships, and how commonly IPF perpetrators attempt to conceal their homicides, the potential for IPFs to be staged as suicidal hangings is significant. As one example, in July 2018, Adrian Basham entered the home of his estranged wife, Samantha Fraser, without her knowledge. He assaulted her and whilst she was incapacitated, he tied a noose around her neck which was secured to the garage door track. Due to being alive at the time of the hanging, Fraser died from strangulation through neck compression. Basham was convicted of the murder in 2022 (Supreme Court of Victoria, 2023). Cases such as this, and links between IPF and strangulation in general, make the increase in suicide by hanging rates in females worrisome, as a small number may be homicides misclassified as suicides.

Strangulation is an overarching term encompassing acts that cause external pressure to the neck. ‘Strangulation is defined as asphyxia by closure of the blood vessels and/or air passages of the neck as a result of external pressure on the neck’ (Sauvageau, 2011, p. 320). There are three forms of strangulation: hanging, ligature strangulation and manual strangulation. Hanging occurs when a constricting band causes external pressure to the neck, with this band being tightened by the weight of the body or part of the body. This can occur through free suspension of the body, known as complete hanging, or through incomplete suspension where part of the body is supporting some of the decedent’s weight, referred to as incomplete or partial hanging. Ligature strangulation arises when a constricting band is tightened around the neck by a force other than the person’s body weight, whilst manual strangulation occurs when external pressure is applied to the neck by hands, forearms or other parts of the body (Sauvageau & Boghossian, 2010). This includes acts such as a chokehold or a lateral vascular neck restraint (LVNR; Champagne, 2020). Consequently, when correctly identified, there are only three possible mechanisms that lead to death in hanging cases, these being: compression of the air passages, closure of the blood vessels of the neck and vagal inhibition arising from pressure on the baroreceptors in the carotid sinus and the carotid body (Sauvageau et al., 2010).

Suicide and concealed homicides

There is a robust body of literature on suicide, indicating there are central overarching factors that influence a person to perpetrate the act. Contributing factors to suicide include a prior suicide attempt, mental health conditions, family conflict, unemployment, social isolation, substance abuse and physical illness (Patterson et al., 1983; Van Orden et al., 2010). Suicide can also be influenced by a history of childhood abuse, exposure to adversity through professions such as the military, homelessness and incarceration. There is evidence to suggest that suicidal ideation or acts can arise through the acute onset of hopelessness, agitation and sleep disturbance, with the interactive nature of these conditions leading to suicidal behaviour (Beautrais, 2001; Beck et al., 1985; Goldstein et al., 2008; Van Orden et al., 2010).

There are four primary aspects that are central to suicidal behaviour. The first two characteristics relate to a suicidal desire, arising from a thwarted sense of belongingness and perceived burdensomeness (Van Orden et al., 2010). In conjunction with these desires, a person must be capable of committing suicide and must have access to lethal means. Thwarted belongingness occurs when someone experiences a shift in their cognitive and affective states, losing their sense of social connectedness. This may include perceiving others’ behaviours as rejection, losing significant social relationships, heightened feelings of being alone and experiencing a loss of meaning (notably, these are also features consistent with experiences of intimate partner violence; see Commonwealth of Australia, 2023). Perceived burdensomeness occurs when an individual perceives that they are a burden and cause of problems for family, friends and associates. Consequently, the person may believe that they are a source of liability and grievance for others, resulting in the perception and belief of being ultimately flawed. This can lead to feelings of self-hatred and worthlessness, marked by the sense of being of little value. Lastly, when these suicidal desires and perceptions occur, the likelihood of suicide is increased when the individual experiences capability-increasing factors. These may include: a history of prior painful and provocative experiences in life (e.g. trauma, adverse consequences, recklessness), increased fear tolerance, non-ambivalence to pain and a reduced fear of death.

If a person dies in Australia, statistically they are much more likely to die from suicide than homicide (11.8 vs. 0.93 per 100,000; ABS, 2024; Miles & Bricknell, 2024). However, in equivocal cases, avoiding bias created by these statistics requires investigators to search for evidence not just supportive of suicide, but also that tends to refute a suicide theory. Of course, the absence of indicators suggesting suicide would challenge it as a viable explanation for an equivocal death. There are also factors that protect a person from suicide, the presence of which could call into question suicide theories. Indicators protective of suicide include, in summary: making future plans and being hopeful or optimistic; having or regaining a sense of personal control or determination; having responsibilities and duties to others, including being a parent or having pets; sobriety; being able to ask for help from others (including services, family and friends, accessing health care); having strong relationships, particularly with family; being in good health; and having coping and problem-solving skills (Centre for Disease Control, 2025; Western Michigan University Suicide Prevention Program, 2025).

Across the research on homicide, or more specifically homicide concealment, there are also a range of factors that have been associated with staging or concealing the death. As outlined by Bitton and Dayan (2019), these include: deaths of women in their own home, deaths that are unforeseen by the decedent’s physician, deaths of women during separation, in the context of domestic violence, or that are discovered by their current or previous intimate partner, and inconsistencies between autopsy findings and narratives of the suicide provided by the next of kin or reporting person, or extrapolated from the evidence.

According to Ferguson and McLachlan (2023), in relationships involving coercive control, manipulation of the evidence after a homicide (i.e. through staging) is an extension of manipulative tactics used when the victim was alive. These tactics are used to assist with concealing the true nature of the death, commonly making an IPF appear as something else, like suicide. This can include things like intimidating witnesses, children or investigators; undermining the victim’s character in life and death; using her isolation to deflect suspicion; minimising, denying and blaming others for past alleged abuse; using children to support innocent narratives; adopting heroic or dramatic false narratives; economic abuse after death; and using coercion and threats, such as by assisting investigators in a disingenuous manner.

Ferguson and Petherick (2016) report that staged suicides commonly involve gunshot wounds or asphyxiation (strangulation, suffocation) as the true cause of death. In their cases, injuries were often made to appear self-inflicted, or scenes were staged in a fashion to comport with the location and type of injuries that had been inflicted on the victim (Ferguson & Petherick, 2016). For example, victims who had been shot were staged to appear as suicides by gunshot, and those who had been strangled or suffocated may be staged to appear as suicides by hanging. In these cases, the body of the victim was commonly rearranged or positioned peri/post-mortem, to facilitate the staged facade. In a quarter of the cases a suicide note was created, and in all fake notes the offender was mentioned by name. Perpetrators commonly cleaned up the true events and removed items from supposed suicide scenes in a manner unrelated to the staging effort. This included valuable and non-valuable items.

Aims of the research

Although a range of empirical research has been conducted specifically on the construct of suicide, and the construct of concealed homicide, there has been limited empirical investigation on the cross-over between them. The question ‘when may a suicide be considered a concealed homicide?’ remains unanswered. Internationally there have been numerous cases where deaths, particularly femicides, have been successfully concealed as suicides for a period of time (Bitton & Dayan, 2019; Ferguson & Petherick, 2016). Among many of these cases, hanging has been used as a method of concealment often to mask strangulation (Monckton Smith, 2019; Rogalska et al., 2015). Strangulation murders leave limited forensic evidence, commonly with no weapon, no body disposal and no need for extensive scene clean-up. Strangulation also permits for simple staging as a suicide, perhaps with only a single point of injury, an absence of forensic evidence from weapons, often limited valuable trace evidence and the ability for offenders to quickly stage a scene after the fact. In this way, staging a suicide by hanging presents an attractive opportunity to perpetrators, which they may choose to capitalise upon.

The present scoping review examines the empirical research on hanging and ligature/manual strangulation deaths, including suicides and homicides staged to appear as suicides. In so doing, the factors used to differentiate suicides by hanging and homicides by ligature/manual strangulation are examined, and indicators for investigators are reviewed. Scoping reviews ‘are an ideal tool to determine the scope or coverage of a body of literature. . . . The general purpose for conducting scoping reviews it to identify and map the available evidence’ (Munn et al., 2018, p. 2). As such the current review intends to examine whether there is empirical evidence in the medical, psychological or criminological literature to differentiate between suicides and homicides in hanging and ligature/manual strangulation cases.

Method

For the present study, a scoping review was chosen in lieu of a systematic review to allow the authors to identify, map and review areas of evidence that assist in differentiating between suicides and homicides in hanging and strangulation cases. Systematic reviews are most appropriate when aiming to critically examine a specific and narrow research question, using systematic and structured methods to derive findings (Higgins & Green, 2011). In contrast, scoping reviews are intended to focus on the scope and coverage of a research area, focusing on what has been found, what may be lacking, and what foundational conclusions can be established (Arksey & O’Malley, 2005). It is often following a scoping review, that a systematic review may arise, promoting a more narrow and focused investigation. According to Munn et al. (2018), ‘if the authors have a question addressing the feasibility, appropriateness, meaningfulness or effectiveness of a certain treatment or practice, then a systematic review is likely the most valid approach. However, authors do not always wish to ask such single or precise questions, and may be more interested in the identification of certain characteristics/concepts. In these cases, a scoping review is the better choice. As scoping reviews do not aim to produce a critically appraised and synthesised result/answer to a particular question, and rather aim to provide an overview or map of the evidence’ (p. 3).

Using Munn et al.’s (2018) scoping review method, a literature search was conducted using the primary data search terms: ‘strangulation’, ‘hanging’, ‘suicide’, ‘neck compression’, ‘lateral vascular neck restraint’, ‘staging’ and ‘concealed homicide’ to extract research papers. A range of scholarly databases were used including PubMed, Google Scholar, ProQuest, Scopus and Science Direct. Following Munn et al.’s (2018) procedure, articles were screened for suitability, discussed between the researchers and selected based on their forensic utility and relevance, with a preference towards case studies, empirical data and medical research. The articles used in the scoping review were selected based on applicability to the focus of the research; however, there is no assumption that the evidence reviewed is exhaustive. Previously archived articles/documents collected by the authors were also included in the review (e.g. court outcomes that are not held in academic databases).

Consistent with the purposes of a scoping review (see Munn et al., 2018), the researchers assessed each article and the collective to: identify the available evidence across the research fields, identify key characteristics and factors relating to the research topic, and identify and analyse the established knowledge and gaps. Through reviewing the extracted body of literature, three primary factors emerged as being central constructs relevant to manner of death. These were: scene, decedent and medical indicators. Whilst a fourth category, perpetrator indicators, was identified, this was excluded from the analysis due to potential for bias and the limited utility that perpetrator indicators/factors provide for investigators in the first instance. As such, conclusions on manner of death need to be based on death scene evidence, victimology and medical findings. Information pertaining to the perpetrator becomes of relevance when inconsistencies arise in the analysis of these initial aspects. However, the possible significance of perpetrator factors is expanded on in the Discussion section.

Results

The results are examined across three areas: scene, decedent and medical indicators. For ease of review, the summarised main findings are presented in tables.

Scene indicators

In some death investigations, cases are solved almost entirely on circumstantial evidence and contextual information. Though autopsy findings are useful to investigators, ‘as in most of medicine, the ability to formulate a differential diagnosis and reach medical opinions in forensic pathology rests heavily on the history’ (Rogalska et al., 2015, p. 490). This means that drawing correct conclusions in hanging and strangulation cases relies on good police work at the death scene and elsewhere as much as on the expert opinion of forensic pathologists. While little scholarship exists specifically identifying scene indicators in suicidal versus staged homicidal hangings, there are some elements of the scene that have been used to point to one over the other in equivocal cases. These include the state of the decedent’s hair relative to the ligature, their dress, the location and security where they are found, the presence of bindings or restraints, the presence and content of alleged suicide notes, items missing from the scene, features of the hanging point and how it is accessed, the ligature itself and any knots apparent in it. These results, and the decedent indicators described in the next section, are summarised in Table 1.

Table 1.

Scene and decedent indicators in hanging and ligature/manual strangulation cases.

Scene/decedent indicator	Suicide by hanging	Concealed homicide, ligature/manual strangulation
key references
Hair Geisenberger et al., 2019	Neat, over ligature	Messy, tangled in ligature/knots, under ligature
Dress Simon, 2008	Decedent is clothed; dress normal for time of day when death occurred, context, acknowledging discovery by others	Decedent may be nude. Dress inconsistent with narrative or context of death, victimology
Bindings Tugaleva et al., 2016 Russo et al., 2016 Gorniak et al., 2007	Wrists, ankles or both may be bound, in front or back	Unlikely to be bound. Binding may be present in homicides without staging
Face covered/oral plug Tugaleva et al., 2016 Douglas & Munn, 1992	Rarely present, to protect discoverer or provide dignity	Rarely present, can represent undoing behaviours
Suicide note Tugaleva et al., 2016 Ferguson & Petherick, 2016 Bennell, Jones, & Taylor, 2011 Jones & Bennell, 2007 Gregory, 1999 Leenaars, 1988	May be present, 20%	Unlikely to be present but if so, mentions offender, content inconsistent with known final communications, may be written by decedent for other purposes
Missing items Videbeck, 2011 Ferguson & Petherick, 2016	Personal items may be given away by decedent	Valuables and non-valuables missing, associated with theft, clean-up (bedding, towels, carpets, clothing), or unknown
Location/security Russo et al., 2016 Ferguson & Petherick, 2016 Bitton & Dayan, 2019 Ferguson, 2015	At/around own home Locked/secure scene	At/around own home Secure or insecure
Hanging points Cooke et al., 1995	Various possibilities	Check against decedent reach, ability to bear weight while decedent moving
Stepping/hoisting mechanism Geisenberger et al., 2019	Logical step present, evidence of decedent on it	Anchor point allows for hoisting, step placed by others
Ligature material Cooke et al., 1995 Commins et al., 2024	Various possibilities Tension on, position of, material of ligature could cause unconsciousness	Check if tension on, position of, material of ligature could have caused unconsciousness
Ligature knots Russo et al., 2016 Chisnall, 2020	Often at the back or side, simple, often tied while facing the knot in comfortable position	May be complex, check consistency with decedent skill set and previous behaviour, sobriety, available lighting, ligature length, reach, position and handedness
Clean-up Cleveland Clinic, 2024 Ferguson & Petherick, 2016	May be present, timing prior to death	Commonly present, timing post mortem. Check for smells, clothing, towels, bedding cleaned or being washed, marks from wiping, mopping
Prior attempts, threats Tugaleva et al., 2016 Ferguson & McLachlan, 2023 Bitton & Dayan, 2019	Likely to be present 36.2% attempts	Rare, if present verify through medical practitioner, friends other than mutual friends with intimate partner
Mental illness Tugaleva et al., 2016 Ferguson & McLachlan, 2023	Often yes, 60% depression, 27.1% substance abuse	Possible. Discriminate between trauma response to abuse versus psychopathology

Hair in ligature

A feature used to differentiate hanging suicides from staged hangings in some cases is the decedents’ hair being wrapped or tangled in, or underneath, the ligature (Baden, 2024; Geisenberger et al., 2019). In a true suicide case, the decedent puts the ligature over their own head or around their neck willingly, meaning involvement of hair is unlikely. Involvement of hair in the ligature is not a documented feature of suicidal hanging deaths in scholarship reviewed. Though so far undocumented, it is possible for this involvement to exist in suicides, when the decedent applies the ligature before fastening it to a hanging point, or before knots are tied. Hair becoming involved in the knots is more likely if hair is long, not pulled up, when the ligature is tied at the back or side of the head and/or the decedent cannot see what they are doing or is intoxicated. In suspected suicides, if hair is involved in the ligature, it needs to be demonstrated that knots could be tied with the ligature in situ, given the decedent’s reach, view, handedness, skill set and sobriety.

In staged homicide cases, a ligature may be put around a victim who is alive, though perhaps injured, drug-affected or unconscious (Geisenberger et al., 2019). In this case, hair being involved in the ligature and knots can evidence that the victim was moving or resisting (Baden, 2024; Supreme Court of Victoria, 2023). If hair is involved in ligatures with knots that are complex or not able to be tied in situ, by someone who may not be able to see what they are doing, and with limited reach or who is not sober, this should be viewed as an indicator of homicide. Hair being messily involved in a knot may also indicate a resisting victim. Conversely, the absence of hair involvement in a ligature should not be viewed as indicative as suicide, as homicide victims are commonly deceased, injured or unconscious when ligatures are applied (Rogalska et al., 2015; Russo et al., 2016), and hair may not be of the length/style conducive to becoming involved or may be tidied up after the victim is hung.

Dress of decedent

How the decedent is dressed can strongly point to suicide or homicide. Alleged suicides where the decedent is dressed in a manner inconsistent with the time or situation when they suicided should raise suspicions. For example, when decedents are dressed for an event or specific time of day (e.g. wearing a work uniform), but then allegedly spontaneously suicide, this can be seen as an indicator of possible homicide. For example, changing from pyjamas into corporate attire may indicate that a decedent had the intention to attend work that day rather than to commit suicide. Decedents, especially women, discovered nude should be considered an indicator of possible homicide, as removal of clothing is commonly used by offenders as a form of clean-up in staged cases (Ferguson & Petherick, 2016; Geisenberger et al., 2019). Nudity (from complete nakedness to partial genital exposure) amongst suicide victims has been observed as uncommon. In one study of 88,982 suicide cases, only 0.4% of victims were found naked (Craun et al., 2022). In cases where a female victim is discovered naked, it is 5.4 times more likely that they are a victim of homicide (Simon, 2008). Female nudity at the time of death should be seen as an indicator of possible homicide or autoerotic asphyxiation (Simon, 2008).

Clothing that is inexplicably dirty, damaged, worn improperly (backwards/inside out, bunched up or pulled down), evidencing dragging or movement of the body, or inconsistent with the alleged timing/circumstances of the death also requires investigation in a supposed suicidal hanging. Like the decedent’s hair, their clothing or jewellery being tangled in, under or involved in a ligature should be viewed with suspicion and requires explanation. Notably, in autoerotic fatalities, padding is commonly seen under the ligature to prevent it leaving a mark on an individual who plans to survive (Byard, 1994). This padding may be in the form of clothing. Padding therefore needs to be discriminated from clothing and other items becoming tangled in a ligature applied in a homicide.

Bindings, restraints and coverings

The presence of bindings, though rare, have been documented in suicidal hanging cases (Gorniak et al., 2007; 2% in Tugaleva et al., 2016). Bindings in hanging cases can involve the wrists or ankles, and in the case of the wrists, they may be tied in the front or the back (Gorniak et al., 2007). Bindings can be in the form of handcuffs, cable ties, cord, laces, rope, tape and clothing (Gorniak et al., 2007; Tugaleva et al., 2016). When bindings are present, they may be tight, but most importantly, are able to be applied by the decedent on themselves. Investigators should inquire as to whether decedents could have manipulated the knots (or other fasteners) with their fingers and teeth, and whether they could they have escaped (Chisnall, 2020).

Items in the decedent’s mouth, presumably to muffle any noise, have also been seen in suicidal hanging cases, as have materials covering the decedent’s face and in, or over, their ears (Tugaleva et al., 2016). Face coverings could also be used to ensure death by adding an element of suffocation; however, they may also appear for other purposes (Tugaleva et al., 2016). There has been suggestion that these items may be used to give the decedent dignity or to protect their appearance for when they are discovered.

In staged homicide cases, offenders most often stage the scene as they think it should appear (Douglas & Munn, 1992). As a result, bindings and other restraints have not been documented in staged suicide cases because they do not represent the basic features of suicidal deaths known to perpetrators. However, bindings have been evidenced in other types of staging, and offenders sometimes stage scenes with no one innocent façade created (Ferguson, 2015). That is, some offenders stage scenes non-specifically, with elements of a robbery, sex crime or suicide seemingly being created. Therefore, if bindings are present, they are most likely to be indicative of suicide if they can be applied by the decedent. They are rarely associated with staged suicides but may occur in non-specific staging cases or homicides without staging. Face coverings have been documented in staged cases previously and may be used by an offender so that they do not have to view their victim’s face (sometimes seen as undoing; Douglas & Munn, 1992).

Suicide notes

In some cases of suicide, a note is left by the deceased. Despite the perception of suicide notes being commonplace, only a minority of suicide victims (of all types) leave notes (Paraschakis et al., 2012). Across studies, there is considerable variation reported regarding the rates of suicide notes being left by victims, with prevalence rates varying between 3% and 42% of cases. In one study that examined the incidence of notes over 21 years of suicide cases, 30.1% of victims were found to leave notes (Kuwabara et al., 2006). Similarly, in a sample of 8140 suicides in Queensland, Australia, 32.5% of victims left suicide notes (Kõlves et al., 2018). These studies indicate that there are no reliable or consistent features differentiating suicide victims that write notes, compared to those that do not. Inconsistent variation has been found across the research in relation to method, prior mental illness, sex and living circumstance, limiting the reliability of conclusions regarding note writing in suicide in general.

In suicides by hanging specifically, suicide notes were found in 20.5% of cases in a large Canadian study (Tugaleva et al., 2016). This means that in most suicidal hanging cases, a note will not be present. In homicides made to appear as suicides, criminologists have discussed the ease with which suicide notes can be staged by offenders (Ferguson & Petherick, 2016). Ferguson and Petherick (2016) discussed faked suicide notes and found that they occurred in 25% of the staged suicide cases examined, though the sample size was small (N = 16). These notes were discovered to be fraudulent because their content was inconsistent with the decedent’s known handwriting or communication style. In all the staged notes, the perpetrator referred to themselves by name, sometimes in ways that were inconsistent with the decedent’s known feelings about them. Bennell et al. (2011) add that there are several characteristics that reliably differentiate true from faked final communications. Using these allows for significantly improved judgments as to the veracity of the note. Jones and Bennell (2007) described suicide notes as highly purposeful, where the author expends great energy directing others to perform actions that they will not be able to accomplish. They found the most powerful indicator of genuine suicide notes was the succinct writing style and expressions of positive affect, including terms of endearment such as dear, love, darling and so on. Jones and Bennell (2007) explain that action verbs (e.g. bury, inform) are more common in genuine notes, rather than cognitive process verbs (e.g. think, regret) seen in other notes. Leenaars (1988) similarly observed that suicide notes contain expressions of positive affect, illustrated in the form of affection, gratitude or concern towards survivors. However, this positive affect may be punctuated over despair. Leenaars (1988) argues this confusion is a defining characteristic. Finally, Gregory (1999) compared 33 suicide notes to a sample of simulated notes, showing that genuine notes have an external locus of control, with suicidal people explaining behaviour and circumstance as a product of fate, luck or other external causes. Gregory (1999) argues that external explanations are used to avoid responsibility and to neutralise the suicidal behaviour. In simulated notes, an internal locus of control is more common. Gregory (1999) also discussed the length of suicidal communications as an important element of consideration, noting that the length and succinct style seen in genuine notes is due to the amount of instruction and information necessary to be communicated.

Along with notes being fabricated, there is also the potential for non-suicidal communications to be used in staged cases to appear as such (Ferguson & McLachlan, 2023). This could take the form of a letter written by the decedent indicating their unhappiness in a relationship, expressing a desire to not continue with things as they stand, in reaction to a death threat being made against them or even as a financial agreement. Offenders may place these communications in a death scene or otherwise draw attention to them, so they appear as possible suicide notes despite being written for another purpose. In hanging cases involving a note where staging is possible, consideration should be given to whether the final communication was physically written and/or authored by the decedent, whether its content is consistent with suicide notes in the scholarship, and whether it might have been created by them for another purpose.

Missing items

Discovering items missing from a death scene should be viewed with suspicion in hanging and strangulation cases (Ferguson, 2015). Staging offenders may remove items that they wish to keep, that they do not want others to find or have, or that they perceive to be valuable. This includes items with and without any financial value – for example, jewellery, electronics, pictures and paperwork. It is worth noting that, in the lead up to suicide, some individuals give away items that are valuable or meaningful to them (Cleveland Clinic, 2024; Videbeck, 2011). Items expected to be at the scene that are missing therefore should be investigated to determine whether they may have been given away to loved ones or witnesses. If so, this may be indicative of suicide, especially when the items are monetarily or personally valuable, and if the decedent relies on them for work, communication and so on.

Location

In an examination of 261 suicides by hanging in Western Australia (Cooke et al., 1995), 71% occurred at the deceased’s home; 28% occurred in the deceased’s bedroom, 37% in a carport or veranda, 21% in a garage or shed, 8% in the garden and 1% in the basement. In their study of hanging deaths, Russo et al. (2016), noted that a secure scene is a key feature of suicidal hangings. However, Bitton and Dayan (2019) discussed scene security in unexpected deaths of women as being a feature characteristic of staged homicide cases. As a result, a decedent being discovered inside their own home that is secure should not be viewed as ruling out the possibility of homicide. Indeed, the majority of victims of staged suicides are discovered in and around their own home or vehicle (72%; Ferguson, 2011).

Hanging points and stepping/hoisting mechanisms

Amongst Cooke et al.’s (1995) cases, 41% of the decedents were completely suspended, and 40% were incompletely suspended (in standing position with feet or toes in contact with the ground or an object), whilst 8% of cases were kneeling, 8% sitting and 1% lying. The most common ligature suspension point was from a rafter on a roof, ceiling or veranda (50.1%) with other points including trees (17.6%), doors or door frames (10%), shower rails (4.2%), pieces of furniture (0.4%), clothes hoists (2.3%), pipes (2%), stair rails (1.5%), wall brackets (0.8%), swings (0.8%) and ceiling hooks (0.8%). In other research, various hanging points have been seen, such as ceiling fans, door knobs and so on.

Because of the variety of hanging points possible, there is little consistency in those seen in suicidal hanging versus staged hanging cases. To discriminate between the two, an assessment of whether the decedent could reach the hanging point, whether it could bear their weight while moving, and whether a stepping mechanism would allow them to access the ligature/hanging point should be considered. It is common for perpetrators staging suicides to include a stepping mechanism as part of the staging effort; however, especially with complete or almost complete suspension, getting the decedent into the hanging position can be difficult. Signs of hoisting or potential hoisting should be noted, such as marks or wear on hanging points and the ligature (Geisenberger et al., 2019), as well as marks on the decedent’s clothes or body indicating that they were laying on the floor beforehand (such as dirt or dust on clothing, bruising on bony protuberances, and so on). Detailed forensic examination of the stepping mechanism should also be undertaken to determine who put it there and whether it would work as a stepping mechanism in the circumstances required.

Ligatures

In Cooke et al. (1995) 59% of suicides by hanging involved a rope as the source of ligature. Otherwise, the most common type of ligature was an electrical cord (13.7%), belt/dressing gown cord (9.6%), sheet/blanket (5%), clothesline wire (2%), garden hose (2%), shirt (1.5%), dog lead (1.1%), curtain (1.1%), neck tie (0.8%) and stockings (0.8%). Other studies have similar findings, indicating that rope, cords, straps and clothing are commonly used as ligatures in hanging cases (Commins et al., 2024). While the type of ligature used in staged hangings has not been discussed in the scholarship (except for in case reports), there appears to be a similar variety present in possible ligatures. As a result, while the ligature material itself may not be indicative of suicide or staged homicide per se, its origin and whether it is consistent with ligature marks on the body and/or the suicidal narrative may provide useful evidence. Notably, some offenders who stage suicides also report discovering the body (44%; Ferguson, 2011) and removing the ligature or cutting the person down to render aid. In cases where this is possible, care must be taken to confirm whether the decedent was ever indeed hanging. This has been done previously by looking for fray marks where the ligature was supposedly cut while bearing weight (Webster, 2025), testing to determine whether the ligature and/or hanging point could bear the relevant weight of the decedent (and/or become tight enough to kill them) especially if they were moving, whether the reporting person could hold the decedent in a fashion to loosen or remove the ligature (Webster, 2025), and what position the decedent would take if they fell from the alleged hanging place (Supreme Court of Pennsylvania, 2014).

Ligature knots

In a study by Commins et al. (2024) of hanging cases in Ireland, 54.7% of the ligature knots were fixed, and 11.8% were running knots. ‘In the remaining cases (33.46%), the type of knot was unknown, as the noose or loop part of the ligature was often undone by people who first discovered the body at the scene, in an attempt to save them or as part of the removal process’ (Commins et al., 2024, p. 3). When knots can be analysed, the decedents’ position, handedness and skill set should be considered. Chisnall (2020, p. 3) remarks ‘there is a moderate yet intricate correlation between knot chirality [direction or orientation] and tier handedness. This relationship depends on the number of wends [ends] the tier is using and other situational factors. . . . Awkward or unusual tying tasks and materials may act as chirality reversal factors – conditions that cause a tier to reverse their innate actions.’ While forensic analysis of knots is complex and requires specific expertise, non-experts can consider that knots tend to be tied while facing the knot in a comfortable position, and the simplest, innately tied knots are most common. However, ‘natural tying behaviour may be confounded by a tier’s inability to acquire the ideal tying position, and whether or not the object being tied is fixed or movable’ (Chisnall, 2020, p. 6).

Intricate knots are rare, with specific skills or training being demonstrated in only 5% of cases (Chisnall, 2020). Indeed, simple knots are used by people repeatedly, because they are effective and easy to tie. Therefore, in hanging and strangulation cases, investigators should be wary of intricate knots, or those that require uncomfortable positioning of the tier. Tangles or accidental knots, especially in long, thin and pliable rope or cord should also be discriminated from purposely tied knots where possible. If it is alleged that a knot came loose on its own or when a decedent was moved, examiners might look for evidence of hitch knots where this is known to occur, and stiff or worn rope, which has been associated with knots working loose (Chisnall, 2020).

Clean-up

Cleaning up evidence of what transpired is a main feature of homicide concealment. It is the most common behaviour perpetrated, along with placement of weapon and lying to authorities (Ferguson, 2015). In homicides made to look like suicide, many perpetrators simply position the body in a manner consistent with suicide (for example, hanging it somewhere) and then clean up or destroy evidence of what occurred. This may be by cleaning up blood, tidying up a mess made during a struggle, wiping or washing a victim or themselves, washing/removing or destroying bedding or towels, and removing, washing or destroying clothing worn by the victim or themselves. In an apparent suicide by hanging, investigators should look for evidence of cleaning up, including on the floors, walls and ceiling, in the washing machine, sinks, garbage and so on. They should be cognisant of smells of cleaning products, as well as missing items of clothing, bedding and towels.

In the suicide prevention research, at-risk individuals cleaning up a living space has been viewed as a warning sign for suicide (Cleveland Clinic, 2024), though this does not appear to have been studied empirically. Evidence that the decedent cleaned up, such as fingerprints or DNA on cleaning products or implements, is therefore important to discriminate between these behaviours. Additionally, evidence of the timing associated with clean-up should be noted, as staging offenders tend to do this after the death, whereas decedents who suicide, of course, do this in the days or hours beforehand.

Medical indicators

There is much controversy in the medical literature surrounding the injuries to be expected in suicidal hanging versus homicidal ligature or manual strangulation cases. This is mostly because, while differences exist in the way these behaviours are carried out, all of them result in external neck compression, making it difficult to identify characteristics unique to any or each of them (Commins et al., 2024). Neck compression can affect the airways or circulation, and/or result in vagal inhibition (stopping of the heart). Some methods and mechanisms cause injury and affect only one function, whilst others can impact multiple functions. Troublingly, a strangulation act that renders a person unconscious or causes their death may also be missed, or masked by the neck compression that occurs through subsequent hanging.

The prevalence of injuries thought to be indicative of hanging and strangulation varies widely in the scholarship, and many conflicting findings exist (Gascho et al., 2019). Adding to the challenge of interpreting these injuries, it is noteworthy that they can be missed, overlooked or even caused during autopsy, or when inappropriate dissecting techniques are used. For example, in a case study published by Rogalska et al. (2015), the death of a 51-year-old female was initially ruled as a suicidal ligature hanging. However, several months after the death, her partner came forward and confessed to murdering her. Following an argument, he choked the victim to death and staged a suicidal hanging. The perpetrator had previously worked as a security guard and had been trained in different ‘choke holds’. Rather than using a traditional arm bar chokehold, which typically involves pressure being applied to the person’s neck (generally the throat and trachea), primarily blocking breathing, and sometimes circulation, the perpetrator used an LVNR. An LVNR (carotid hold), does not impede breathing but rather restricts circulation to render a person unconscious. As outlined, ‘LVNR differs from a “choke hold” because it impacts the circulatory system while leaving the airway unobstructed and protected during the confrontation’ and applies pressure to underneath the jawline (Huth, 2013, para. 10). An LVNR can cause someone to lose consciousness in around 7–15 seconds. When correctly applied and if release occurs promptly, a person can regain consciousness in around 30 seconds (Haynes, 2009). However, if an LVNR extends beyond one minute, a prolonged loss of consciousness and death can occur (Champagne, 2020). Due to LVNR restricting circulation, ‘there is often no soft tissue, bone, or cartilage injury’ (Rogalska et al., 2015, p. 488), making the method difficult to detect post mortem and easily overlooked when other injuries are present (such as neck compression from a ligature).

Ultimately, the detection of injuries is based on subjective assessments according to the experience of the examiner (Gascho et al., 2019). The examiner’s interpretation of the injuries usually considers the circumstances under which the death is thought to have occurred to draw conclusions surrounding mechanism, medical cause and manner of death, creating additional layers of subjectivity. Injuries typical in these cases, and how they can be interpreted to point towards hanging and ligature/manual strangulation, are described below and summarised in Table 2.

Table 2.

Medical indicators in hanging and ligature/manual strangulation cases.

Medical indicator key references	Suicide	Concealed homicide, LS/MS strangulation
Fractures in the necka Gascho et al., 2019 Godin et al., 2012 Yen et al., 2005	Fractures may be present Hyoid bone Thyroid cartilage Cricoid cartilage very rare Lymph node very rare	Fractures common, especially in MS Hyoid bone Thyroid cartilage Cricoid cartilage Lymph node
External injuries Tugaleva et al., 2016 Thomsen et al., 2022 Commins et al., 2024 Geisenberger et al., 2019 Rogalska et al., 2015	May have injuries associated with ligature, bruises, abrasions, attempts to remove it, fingernail marks rare Neck injuries away from ligature mark rare, usually single abrasion or bruise, scratches Present in complex suicide and obvious (gun shot, sharp force neck, wrists) Injuries from fall from hanging place are rare, when present, minor blunt force Injuries from prior attempt may be present	Common. Abrasions, contusions of jawline, chin, neck; external soft tissue injuries (not ligature marks) 50% LS, 100% MS Between 6 and 10 injuries Defensive/associated with removing ligature rare Note other blunt, sharp force injuries, especially dragging or hoisting injuries Injuries may not be present with LVNR
Internal soft tissue haemorrhages in the neck Commins et al., 2024 Yen et al., 2005	Rare (2–3%)	Commonly present (30–56%) Lymph nodes should be examined
Petechial haemorrhages Russo et al., 2016 Thomsen et al., 2022	May be present	Very common
Ligature mark Russo et al., 2016	One or two if ligature double wrapped, positioned under jaw; slanting from bottom to top, front to back; mark interrupted by knot	One or two if double wrapped, may be additional horizontal ligature marks, may not have interruption from knot
Toxicologyb( Commins et al., 2024 Tugaleva et al., 2016	Common. 28–31% alcohol/illegal drugs; 5.3% above therapeutic levels of prescriptions (anti-depressants, benzodiazepines)	Rare; alcohol when present
Tongue presentation Commins et al., 2024 Russo et al., 2016 Bockholdt & Maxeiner, 2002	Protruding 19–28% Usually no injury; bite marks rare	Protruding 10% LS, 0% MS 71% injury, 19% bite marks

Note: LS = ligature strangulation; MS = manual strangulation; LVNR = lateral vascular neck restraint.

^aSee Table 3 for more details. ^bSee Table 4.

Fractures

Fractures of the hyoid bone, thyroid cartilage and cricoid cartilage represent perhaps the most controversial injuries in hanging and ligature/manual strangulation cases. The research is conflicting regarding the types of fractures likely to occur in these cases, with some studies reporting that thyroid cartilage fractures occur more frequently in cases of hanging than in strangulation and other studies finding the opposite (Commins et al., 2024). Some studies find more hyoid bone fractures in cases of hanging than strangulation, while others find the reverse (Commins et al., 2024). For example, in a study of hanging and ligature/manual strangulation cases in Ireland, Commins et al. (2024) found fractures in 29% of hanging cases and 16% of strangulation cases. In another study, Schulze et al. (2018) found fractures occurred in 60% of hanging cases. Thomsen et al. (2022), studying asphyxia homicides in Denmark, found that fractures of all types are more common in homicides with an element of manual strangulation, and that hyoid bone, and cricoid cartilage fractures specifically, are uncommon in ligature strangulation cases. Godin et al. (2012) found cricoid fractures virtually non-existent in suicidal hanging cases but occurring in up to 20% of homicidal strangulations. They note that the presence of this fracture should be viewed as highly suspicious in apparent cases of suicide by hanging; however, this finding does not appear to have been validated elsewhere, except in Thomsen et al. (2022) who found that cricoid cartilage fractures occurred in manual strangulation but less so in ligature strangulation cases. A summary of the findings related to fractures is presented in Table 3.

Table 3.

Fracture and soft tissue injuries in hanging and ligature/manual strangulation.

	Source	Hanging suicide		Ligature strangulation homicide		Manual strangulation homicide
		n/N	%	n/N	%	n/N	%
Fracture of the hyoid bone	Gascho et al., 2019	26/106	24.5	2/12	16.7	2/6	33.3
Fracture of thyroid cartilage	Gascho et al., 2019	26/106	24.5	4/12	33.3	2/6	33.3
Soft tissue haemorrhage	Gascho et al., 2019	24/106	22.6	5/12	41.7	5/6	83.3
Gas bubble sign and any fracture	Gascho et al., 2019	19/35	54.3	No data		No data
Gas in soft tissue	Gascho et al., 2019	15/52	28.2	No data		No data
Cricoid fracture	Godin et al., 2012	1/270	0	5–20		5–20
Lymph node haemorrhage	Yen et al., 2005	0		No data		100

In a review of the literature focusing on fractures by Gascho et al. (2019), it was determined that the position of the hanging knot plays a role, as an anterior knot position is unlikely to cause a hyoid or thyroid fracture compared to other knot positions. Commins et al. (2024) noted that a hard, fixed noose can also increase the chance of fractures. It appears that the presence of fractures may be better predicted by factors other than mechanism and manner of death, including age (fractures increase as age advances; Schulze et al., 2018), sex (more common in men than women; Commins et al., 2024; Godin et al., 2012), size of the internal structure (longer, wider, hyoid bones are more susceptible to compressive trauma; Mukhopdhyay et al., cited in Commins et al., 2024), height (Commins et al., 2024) and BMI (at least in hanging cases; Tugaleva et al., 2016). It is important to note that subtle fractures are also commonly missed at autopsy, unless special techniques are applied (Maxeiner, 1998; Thomsen et al., 2022). Moreover, along with hanging and strangulation cases, these fractures have also been discovered in cases involving blunt force trauma to the neck and motor vehicle accidents, with one review of autopsies reporting the incidence of hyoid bone fractures due to motor vehicle accidents to be significant (35.9%; Dunsby & Davison, 2011). Fractures may also occur during the handling of the body at the scene, in transit and during the autopsy itself (Commins et al., 2024). Therefore, using fractures alone to determine whether a death is likely to be from hanging or strangulation should be done with great caution.

External soft tissue injuries

The presence of external soft tissue injuries in hanging and strangulation cases offers more insight into establishing manner of death; however, the presence or absence of these injuries is not without controversy. Commins et al. (2024, p. 6) found ‘the extent of external and internal soft tissue injuries recorded in cases of homicidal ligature and manual strangulation in comparison to those observed in cases of complete/incomplete hanging presents a potential differentiating factor’. These injuries may be subtle depending on the ligature type used, if any, but according to Thomsen et al. (2022, p. 1778) ‘lesions on the jawline/chin should be considered markers of trauma to the neck and possible [homicidal] strangulation, warranting further investigation’. Commins et al. (2024) found external soft tissue injuries (not including ligature marks) in 50% of ligature strangulation and 100% of manual strangulation cases. In manual strangulation cases, the number of injuries was 6–10 per case. In hanging cases, external soft tissue injuries were present in only 12–14% of cases and usually amounted to a single abrasion or bruise. Tugaleva et al. (2016) made similar findings with injuries to the neck away from the ligature being rare (∼1%) and ‘periligature injuries’ present in only 7% of hanging cases. They found that other injuries, such as from complex suicides, other self-inflicted injuries (such as fresh and old cuts to extremities, chest and neck), previous failed attempts at hanging or falling from a failed ligature, were also relatively rare.

Injuries specifically attributable to trying to remove the ligature (e.g. from fingernails) were rare in strangulation cases in Commins et al.’s (2024) review, and Tugaleva et al. (2016) found fingernail marks near the ligature in 0.3% of hanging cases. Other injuries that may be defensive on the neck or otherwise are, of course, of great importance as they may indicate a physical assault along with the strangulation and/or attempts to remove a ligature. Defensive injuries may be from blunt or sharp forces; they can appear across the entire surface of the neck (including bruises, scratches and abrasions; Commins et al., 2024) and in other places on the body. Caution must be taken to attribute these properly to assaults, rather than falls from a failed ligature or previous unsuccessful hanging attempt. Blunt or sharp force injuries contributing to death are not uncommon in strangulation homicides, and therefore signs of assaults of this type must be discriminated from self-inflicted injuries and falls (Thomsen et al., 2022). Injuries that may be from dragging or moving a dead or unconscious person, such as to the boney protuberances, are particularly significant (Geisenberger et al., 2019). While the absence of these types of injuries may point to suicide, as noted above, case reports exists where fatal chokeholds are applied and leave no injuries (Rogalska et al., 2015). In sleeper holds (or LVNRs), the neck is squeezed bilaterally in the crook of the assailant’s arm resulting in rapid unconsciousness with little discomfort. In this situation ‘the rapid loss of consciousness and relatively secure positioning make struggle less effective in displacing the arm, and reduce the chance of visible injury on either the skin or the internal structures of the neck’ (Rogalska et al., 2015, p. 488).

Internal soft tissue injuries

Internal haemorrhage in tissues of the neck appear most commonly in strangulation, as opposed to hanging (30–56% vs. 2–3%, respectively; Commins et al., 2024). These injuries are to be expected in homicidal strangulation but are not always present and may be impacted by decomposition (Thomsen et al., 2022). They can occur in hanging cases, especially in certain circumstances (e.g. long drops), but appear less often. Yen et al. (2005) made similar findings when it came to lymph node haemorrhage, indicating that it was present in all cases of manual strangulation examined and only one case of hanging. However, the manual strangulation cases examined (n = 4) involved choke holds or kicking to the neck, which may impact on the presentation of lymph node haemorrhage in this study.

Petechial haemorrhages

Petechial haemorrhages are common in both hanging and ligature/manual strangulation deaths (Russo et al., 2016; Thomsen et al., 2022). Thomsen et al. (2022) found petechial haemorrhaging in 85% of strangulation cases, and that specific to the conjunctivae in 83%. Russo et al. (2016) found conjunctival petechiae in 11% of hanging deaths and internal petechiae of various types ranging from 15 to 56%. Thomsen et al. (2022) note ‘from our study and previous studies, it is safe to say that a lack of petechial haemorrhages, especially in the conjunctiva, is rare in homicidal strangulation, but there are exceptions, especially when there is post-mortem decomposition’ (p. 1778). The presence of petechiae is therefore not a particularly powerful discriminator between suicide and homicide, though the absence of petechiae appears much more commonly in hanging deaths rather than homicides by strangulation.

Ligature marks

Ligature marks, including the position, angle, depth, continuity and thickness, appear to be one of the most important indicators for establishing manner of death, determining between hanging and ligature/manual strangulation (Russo et al., 2016). Comparison of these marks with the supposed ligature, the thickness of each, the continuity of the mark and placement of knots, how many times the ligature is/was wrapped around the neck (almost always 1; Russo et al., 2016), and whether there are multiple marks are key to establishing whether the alleged ligature caused the death, and whether other ligatures or manual strangulation might also have been involved. The ligature mark is often easily detectable during the external examination, meaning at least general assessments can be done by investigators ahead of detailed medical examinations. In hanging deaths, usually the ligature mark is angled from bottom to top and front to back (96%) and is positioned above the thyroid cartilage under the jaw (in 62% of the cases; Russo et al., 2016). This pattern is one of the main signs of hanging differentiating it from ligature strangulation, where the ligature mark runs horizontal and often under the thyroid cartilage (Russo et al., 2016).

Toxicology

The presence of positive toxicological examinations may also be useful in determining between hanging and ligature/manual strangulation cases. Tugaleva et al. (2016) found that positive toxicology results are rare in homicide cases, and, when present, decedents are usually positive for alcohol. Conversely, toxicology results are commonly positive in suicidal hanging cases, with alcohol and illegal drugs being present, and antidepressants sometimes in higher than therapeutic levels (Tugaleva et al., 2016). Commins et al. (2024) made similar findings regarding toxicology, which are summarised in Table 4.

Table 4.

Toxicology in hanging and ligature/manual strangulation cases.

	Hanging		Ligature strangulation		Manual strangulation
	n	%	n	%	n	%
Ethanol	88	30.6	4	40	8	89
Anti-depressants	72	25	0		1	11.1
Cocaine	19	6.6	0		1	11.1
Opioids	15	5.2	1	10	1	11.1
Benzodiazepines	75	26	1	10	4	36.4
Anti-psychotics	33	11.5	0		0
Paracetamol/NSAIDs	24	8.4	4	40	0
Cannabis	13	4.5	1	10	1	11.1
Anti-convulsants	0		0		2	18.2
Total	287	100	10	100	9	100

Note: NSAIDs = Non-steroidal anti-inflammatory drugs. Summarised from Commins et al., 2024.

Presentation of the tongue

Russo et al. (2016) found the tongue to be protruding in 19% of hanging deaths, while Commins et al. (2024) found this in 28% of hangings. In the latter study, the tongue was protruding in only 10% of ligature strangulation cases and in zero manual strangulation cases (Commins et al., 2024). Tugaleva et al. (2016) found that injuries or bites to the tongue were rare, occurring in 0.1% (7 of 632) of hanging cases. Bockholdt and Maxeiner (2002) found injuries to the tongue in 71% of strangulation homicides, including bite marks in 19%. Similar findings occurred in only 8% of suicides by hanging, with bitemarks in only 1%. Taken together, these findings suggest that the tongue protruding is more indicative of hanging than strangulation, but the absence of tongue protrusion can occur in both case types. Injuries to the tongue sometimes occur in hanging cases but appear much more indicative of strangulation.

Decedent indicators

In a study of suicide trends in Australia (Kõlves et al., 2018), 3939 people died by hanging (broad use of terminology) between 2000 and 2015. Amongst these individuals, 81.3% were male and 18.7% females, with mental illness present in 42.5% of the cases and prior alcohol consumption in 33.1%. Cooke et al. (1995), found similar levels of alcohol consumption. Approximately 30% of Kõlves et al.’s (2018) cases had a prior suicide attempt, with 50% having interpersonal conflict prior to their death and 17.9% having financial or employment issues. Tugaleva et al. (2016), found that mental illness was often present in their suicidal hanging cases, with 60% of decedents suffering depression, and 27% with substance abuse. In the same study 36% of decedents had prior suicide attempts.

It is difficult to establish reliable risk factors for suicide amongst people with mental illness. Firstly, this is due to mental illness being a broad and all-encompassing term that can include a range of symptoms and pathology. For instance, a higher risk of suicide has been identified for those with post-traumatic stress disorder, whilst those with borderline personality disorder have been reported to have a 10-fold increase in suicide (Chesney et al., 2014; Nordentoft et al., 2013). However, although both classified as forms of mental disorders, the two conditions vary greatly. Secondly, there is a lot of variance in how mental illness is defined and reported, with some studies including self-harm, threats of suicide and suicide attempts. This creates further challenges when seeking to examine the implications that mental illness may have for establishing suicide. Despite these limitations, more reliable predictions can be made in cases of severe mental illness – primarily schizophrenia-spectrum disorders and bipolar disorders – with relatively higher risk of suicide associated with these conditions (Senior et al., 2020).

With the relationship between mental illness and suicide poorly established, the presence of a combination of factors is likely to prove more reliable in determining suicide. Factors for consideration include social isolation, previous suicide attempts, severe mental illness, drug use, present psychological distress and the loss of positive and protective factors within the person’s life (Batty et al., 2018; Beck et al., 1985; Patterson et al., 1983; Goldstein et al., 2008). These factors should be viewed as correlates rather than predictors, with the presence of more correlates thought to indicate increased risk; however, the weighting of these individually has not been validated or established empirically (Klonsky et al., 2016).

In staged suicides, reports of suicidality, threats or attempts and mental illness can be manufactured by offenders to lend credence to the staged façade (Ferguson & McLachlan, 2023). These types of homicides and staging also often occur in relationships where there are histories of abuse (Ferguson & McLachlan, 2023) and therefore the possibility of associated trauma-responses by victims. If staging is suspected, reports of mental ill health and suicidal tendencies should be verified with the decedent’s physicians or mental health professionals, as well as friends and family who are not associated with the decedent’s intimate partner. Deaths that are unexpected by medical and mental health professionals should raise suspicion (Bitton & Dayan, 2019). Offenders may also manipulate witnesses by telling them that a decedent was troubled or mentally ill, knowing they are likely to believe and corroborate this version of events later. In these cases, investigators must make specific inquiries to determine whether witnesses saw evidence of mental illness beyond what they have been told. Evidence of mental ill health should also be examined to determine whether symptoms are the result of living with abuse. If so, pending separation of the relationship may be viewed as protective against suicide rather than a trigger, and as a risk for homicide. It should be noted that in staged cases, offenders also commonly capitalise on vulnerabilities in the victim to make the staged scenario more credible (Ferguson & McLachlan, 2023). In this way, offenders may choose to stage suicides for victims that have known mental health issues, because of the plausibility this history adds to the false scenario.

Discussion

According to Tugaleva et al. (2016, p. 1503), ‘the typical [suicidal] hanging victim is a young or middle-aged male with a history of prior mental illness and suicidal tendencies who is found suspended in a secure location’. The typical victim of a staged suicide is a female who is involved in an abusive relationship, perhaps with a history of strangulation and who may be attempting to separate from the abuser (Ferguson & McLachlan, 2023; Ferguson & Petherick, 2016). She, too, is often found in a secure location, usually her own home (Bitton & Dayan, 2019). Though these two profiles are distinct, the reality of determining between hanging and ligature/manual strangulation cases to establish manner of death is often complex and dependent on a holistic assessment of scene, victimological, medical and circumstantial evidence. For investigators attempting this, the results of this scoping review suggest an alarming lack of consensus in the literature regarding what various indicators mean, and how they are best used to establish manner of death. While more detailed research is clearly required, this review has produced some modest takeaways for professionals working in this complex space.

Factors at a death scene that are suggestive of staging in hanging cases are often context specific. To decide manner of death, investigators must compare the narrative of the death to the evidence to determine whether they align. This should be done noting that if a homicide is staged as a suicide, the most likely perpetrator is also the next of kin and/or reporting person, meaning that they are likely to provide the first history of the decedent, which can impact heavily on working theories of the case. The privilege associated with being the next of kin or reporting person means these individuals have an opportunity to set the investigation in motion and many capitalise upon this with significant effect (Ferguson & McLachlan, 2023); this includes by blaming the decedent, recruiting others to corroborate their version and convincingly but disingenuously assisting authorities. This scoping review suggests that signs of a physical altercation around the time of the supposed hanging are key indicators of homicide and often represent the inconsistency between narratives and evidence first identified by police. These include the victim’s hair and jewellery being incorporated into ligatures, their clothing being absent or not fitting the suicide scenario, evidence of clean-up and unexplained absence of items from the scene.

Along with looking for signs of an altercation, a thorough assessment of victimology remains crucial to determining between hanging and strangulation cases. Investigators must thoroughly consider all aspects across a person’s life as there is no one profile of a suicidal person. Whilst mental illness, previous suicide attempts and recent psychological distress remain valuable risk indicators, there is also a need to consider protective factors and evidence of planning and scheduling of future life activities (Batty et al., 2018; Klonsky et al., 2016). An indication that a person is organising future activities in the weeks and days prior to their death can suggest that suicide was unlikely. Moreover, protective factors, such as a loving relationship, support, employment and hobbies typically reduce the likelihood of someone committing suicide, although notably, the loss of or threat to protective factors can lead to psychological distress and maladaptive coping responses, in which suicide could occur in some instances. The absence of these indicators of suicide, and families’ continued disbelief at their loved one suiciding, remain important factors that should not be ignored by investigators.

Medical indicators remain controversial, especially with regard to fractures. This review has solidified the well-known tenet in the medical community, that a diagnosis is only as good as the history gathered (Rogalska et al., 2015). Investigators could benefit from understanding that medical opinions are based on the information provided by police and can be hotly contested amongst various experts. Because of this, unfortunately medical opinion may not be the golden ticket to determining manner of death in hanging and ligature/manual strangulation cases but should instead be viewed as one part of a larger, sometimes developing, puzzle. However, evidence of injury to the jawline and tongue remain important factors, which investigators may ask medical experts to consider.

The results show that the long-held view that manual strangulation relates solely to hands being placed around a person’s neck is misguided and fails to account for other manual methods that may lead to death by strangulation. With the increasing popularity of ju-jitsu and mixed martial arts, there is increased knowledge amongst members of the public around the use of chokeholds, or more specifically, LVNR. Adding to this, many professions are trained in LVNR, such as some police, security professionals and military personnel. Whilst these professions provide valuable services to the community, studies have demonstrated that some of them, such as security guards, are more inclined to have personality disorders (antisocial or borderline personality), suffer depression and engage in substance use (Ahmad & Mazlan, 2013). Further to this, greater rates of hostility, anger and physical and verbal aggression have been found amongst these individuals (Ahmad & Mazlan, 2012, 2013). In addition, policing and military roles have been associated with greatly increased rates of intimate partner violence internationally (Avila, 2015; Goodmark, 2016; Heyman & Neidig, 1999), making training in these holds more worrisome given the documented relationship between strangulation, IPF and concealment.

The findings from this review indicate that hanging and strangulation cases need to be thoroughly investigated, particularly when the decedent is a female who is discovered by a former or current intimate partner. Given the breadth of factors and the lack of well-established scene, decedent and medical indicators, investigations need to examine a case in its entirety, rather than relying on selective information to reach conclusions. Often, hanging cases are promptly ruled as a suicide by first responders, resulting in many scene indicators being overlooked, along with important decedent details. While in certain instances, suicide can be established more easily, there appears to be a need for investigators to improve their responses and processes when it comes to hanging and strangulation cases – this may come in the form of a decision-making model or standardised criteria that must be employed for these cases, rather than ad hoc and unstructured responses.

There remain many gaps and limitations for determining manner of death in hanging and ligature/manual strangulation cases. The findings highlight the need to scrutinise medical opinions, conduct thorough scene investigations, complete a comprehensive analysis of the decedent’s life and incorporate circumstantial information. The best case scenario for establishing manner of death in hanging cases involves a process of deliberate steps and stages completed in its entirety, rather than being piecemeal, fragmented and confirmatory.

Ethical standards

Declaration of conflicts of interest

Claire Ferguson declares no conflicts of interest.

Nathan Brooks declares no conflicts of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.