Suicide by fire in Scotland: 1980–1990

Journal of Clinical Forensic Medicine (1996)3, 81-85

©APS/PearsonProfessionalLtd 1996

ORIGINAL C O M M U N I C A T I O N

Suicide by fire in Scotland: 1980-1990 T. J. Squires, A. Busuttil Forensic Medicine Unit, University of Edinburgh, Edinburgh, UK SUMMARY. Suicide by fire is relatively rare in the Western world, accounting for approximately 1% of completed suicides by all methods. This survey identified suicidal deaths among fatalities known to the Scottish Fire Brigades as having died in a fire incident during 1980 to 1990. It is accepted that this is just one possible definition of what constitutes a suicide by fire. Forty cases were identified as suicides from the circumstances of the death as narrated in the police and Fire Brigade reports of the incident. Autopsy and toxicological reports were examined for all cases and the characteristics of the victim and the incident are described. Most cases occurred in the home of the victim and three-quarters of the victims were pronounced dead at the scene or when first seen by a doctor. Smoke inhalation was the most frequently certified cause of death. Alcohol was present in less than half the cases and toxicological analysis for drugs was performed in the minority of cases. One-quarter of victims were reported to have made at least one suicide attempt previously. A range of apparently precipitating factors was observed: the number of cases which appeared to be impulsive responses to life events suggests that prevention is difficult.

Journal of Clinical Forensic Medicine (1996) 3, 81-85

In the period following the Second World War, Sir Sydney Smith suggested that death from selfimmolation was 'almost unknown' in Europe. 1 Although suicide by fire remains a comparatively rare method of suicide in the Western world, 2,3 forensic investigators should always consider the possibility that an apparently accidental fire fatality is a suicidal death. The possibility of criminal involvement should also not be neglected. 4 This study is based on cases of fire related suicide derived from a survey of all fire fatalities in Scotland between t980 and 1990 and describes the characteristics of the fatalities and methods of suicide. During this period there were 1674 fatalities reported by the 8 Scottish fire brigades. The official statistics indicate that there were 5818 suicides (male: 4117, female: 1701) in Scotland over this time interval?

geographical area of his or her jurisdiction, and is further required to submit a report to the Crown Office if the circumstances of the death indicate a possible suicide. For the purposes of this study, a death in a fire was considered to be a suicide if: 1. The circumstances of the fire as reported by the Fire Brigade did not support accidental or malicious ignition. 2. Other circumstances (such as a suicide note or verbal intimation) indicated a suicidal intention. The recommendation of the Procurator Fiscal as stated in his or her report to the Crown Office was an important but not a determinative factor. Records of fire deaths maintained by the 49 Procurators Fiscals, covering all of Scotland, were examined. These files invariably included the police, autopsy, toxicology and fire brigade reports. A summary of all the relevant information was obtained from the Procurator Fiscal's report. Medical information was obtained from the police, autopsy and Procurator Fiscal's report. These data are obtained by the police from the deceased's general practitioner and hospital records as part of their routine investigation into sudden death. In a minority of cases, copies of hospital or general practitioner notes were also available.

METHOD

The Procurator Fiscal is obliged to investigate all sudden, suspicious and unexplained deaths within the I". J. Squires PhD, A. Busuttil MD, FRCPath, Regius Professor of Forensic Medicine, Forensic Medicine Unit, University of Edinburgh Medical School, Teviot Place, Edinburgh EH8 9AG, U K 81

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RESULTS

Table

During the 11-year period of the study, 40 suicides were identified from deaths reported by the fire brigades following fire incidents. The sex distribution was 26 males and 14 females. The mean age for both sexes was similar; male: 41.3 years (20-71 years), female: 46.9 years (23-73 years). Explicit suicide notes or statements of intent were present in six cases

2 - Certified causes of death in suicides by fire

Cause o f death

Number

%

Smoke inhalation Burns Combination (burns and smoke) Other U n k n o w n (not in file) Total

16 14 7 2 1 40

40.0 35.0 17.5 5.0 -

(15%). Duration of survival

Location of the death The location o f the suicide is indicated by Table 1. The majority of cases occurred within the home of the victim. O f the seven cases which occurred in motor vehicles, five were male and two female. One case occurred in hospital. Cause of death A post mortem examination was performed in 35 (87.5%) cases. Table 2 shows the causes of death (certified as the primary cause of death (cause Ia) on the official Death Certificate) in the 40 cases. In the five cases in which no post mortem examination was instructed, death was certified on the basis of a 'view and grant' procedure in which only an external examination of the body was performed. The two deaths in the 'other' category involved a combination of fire with another method of suicide. One death was certified as burn injury in conjunction with a drug overdose. The other victim died of the aspiration of vomit following a fall from a height after he had ignited his clothing. A contributory cause of death (cause II on the Death Certificate) was stated by the certifying pathologist in four cases: 'chronic alcohol abuse', 'ischaemic heart disease and schizophrenia', 'drug overdose' and 'bronchopneumonia and renal failure'. Two cases were reported at autopsy as having incised wounds to the wrist. In both cases, these selfinflicted injuries were not life threatening and neither injury was mentioned on the death certificates. The presence of soot in the respiratory tract was reported in 28 (90%) of autopsied cases. One victim was found to be pregnant at the time of her death. Table 1 - Location of suicides by fire Location

Number

%

Victim's h o m e Vehicle Other (internal) Other (external) Total

26 7 4 3 40

65.0 17.5 10.0 7.5 -

Thirty one (77.5%) cases were dead at the scene or were found to be dead on arrival at hospital. Eight patients survived to 24 hours and four cases survived for 1 week after the incident. One patient who had recovered from burn injuries received after she ignited herself with an accelerant, drove her car at high speed into a wall yet survived the incident because she was thrown clear o f the vehicle. The eventual mechanism of suicide was the self-removal of an intravenous drip. The cause o f death in this case was certified as 'burns'. Alcohol intoxication Table 3 shows blood alcohol concentrations assayed at post mortem toxicology. In three male cases, alcohol was stated by the Procurator Fiscal in his report to be 'present' but was not quantified by toxicology. All alcohol positive cases had levels in excess of the currently prescribed legal limit for driving in the U K (80 mg/100 ml.) Although more males were subject to post mortem alcohol toxicology than females, the difference between the testing rates is not statistically significant. Alcohol was mentioned as a contributory cause of death on one death certificate in this series. This 47-year-old male had a blood alcohol level of 220 mg/100 ml and the death certificate referred to a history of chronic rather than acute abuse. Previous history of decedent Table 4 lists the incidence of psychiatric conditions. Fifteen fatalities (37.5%) were reported to have been suffering from depression. In 50% of the male victims in this series the files did not record any specific psychiatric condition. There was no significant difference between the rates of psychiatric illness in the male and female groups. One patient who was a resident of a psychiatric hospital suffered from schizophrenia, the psychiatric condition of the other in-patient was not recorded.

Suicide by fire in Scotland: 1980-1990

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Table 3 - Blood alcohol concentrations and suicides by fire

Blood alcohol (rag 100 mU)

Male

% (of number)

Female

% (of number)

Nil <80 80<160 >160

10 0 2 6

55.6(18) 11.1 (18) 33.3 (18)

4 0 1 3

50.0 (8) 12.5 (8) 37.5 (8)

Total quantified cases: N o alcohol toxicology Total

18 8 26

69.2 (26) 30.8 (26) -

8 6 14

57.1 (14) 42.9 (14) -

Ten cases (25%) were reported as having made a previous suicide attempt. N o n e of these reported previous attempts were by a fire related method. The police reports did not include any reference to previous criminal convictions in any of the cases in this study, and there was no evidence that any person in the series had been associated with other acts of wilful fire-raising prior to the suicidal act.

Drug toxicology In 65% (26) of cases, toxicology for a range of drugs was not performed. Fifty-seven per cent of cases in which toxicological analysis was instructed by the procurator fiscal produced a negative result. Five cases had drug levels lying at the high end of the therapeutic through to the toxic range. Only one case had drug levels stated by the toxicologist to fall within the fatal range and the death certificate stated that the drug overdose (involving anti-depressants which had not been prescribed to the patient) was a contributory cause of death. In one case in which the toxicologist reported a level of diazepam within the therapeutic range, the term 'drug overdose' appeared as the primary cause (Ia) in combination with burns.

Event precipitating suicide In four male cases, the suicide was preceded immediately by the break-up of a relationship. A common theme in these cases was the existence of a relationship between the female former partner and another male. One of these men killed himself in the presence of his former girlfriend and her new partner. Another male killed his wife (whom he suspected of having an Table 4 - Reported psychiatric conditions

Condition reported

Male

Female

'Depression' Alcoholic 3 Schizophrenic Psychiatric in-patient 'Psychopathic' No condition recorded Number o f victims

9 3 3 1 1 13 26

6 2 1 0 5 14

extra-marital affair) and children before taking his own life in a domestic conflagration. A further dyadic death involved a woman who killed her husband and then immediately committed suicide. Other cases in this series were apparently provoked by a range of factors: a father killed himself after his daughter made an allegation of sexual abuse against him, one male feared that he had become H u m a n Immunodeficiency virus (HIV) positive after receiving a blood transfusion (a post mortem test for HIV antibodies was negative) and a female took her own life when her husband (who had recently been released from prison after serving a sentence for the murder of her father who had abused her three children) died suddenly of a 'heart attack'. There were no cases of suicide pacts in this series. Over one-quarter of this series (one-third of males) were unemployed at the time of death.

Cause of fire Liquid accelerants such as petrol or paraffin (kerosene) - poured directly onto clothing or used to ignite the surrounding environment (e.g. the interior of a car) were identified by the fire brigade investigators in 23 cases. A gas supply was identified as the ignition source in three cases. An unusual case involved a female who wrapped an electric blanket around her head. This resulted in a slow smouldering fire and the victim died after inhaling toxic fumes. In the case of the psychiatric in-patient, the deceased ignited her clothing using matches and no accelerant was used. In 12 cases, the exact mechanism was undetermined by the fire brigade although the fire was stated to have involved a combination of paper, clothing and furnishings ignited deliberately using a primary ignition source such as a match or gas burner.

DISCUSSION Official statistics 5utilise the ICD codes E950-E958 for suicidal deaths. Although fourth digit codes are not published routinely, within the 'other and unspecified

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means' (E958), code E958.1 is reserved for suicide by burns and fire. There were 22 male and 14 female suicides coded E958.1 between 1980 and 1990. The majority of suicides fall within the E950-E956 categories. 5,6 • There is no public classification of suicide in the Scottish medico-legal system and the determination of the ICD code for an individual death is not within the public domain. The strict evidential rules employed by the Crown's legal officers are accepted to result in an under-reporting of suicide in the official statistics, 7 some suicidal deaths in Scotland being classified as undetermined (E980-E989). The requisite evidence of suicidal intent is often particularly elusive in cases of death due to drowning (E954/E984) or poisoning due to solids or liquids (E950/E980). 8 The annual rate derived from this series over the period of the study is less than four cases per annum. This compares with studies in England and Wales which have reported an average annual figure of 23 cases (1963 to 1978) in a population approximately 10 times as large as Scotland? There was no evidence in the current series of any epidemic phenomenon and the fluctuation over the period of the study was not significant. As a proportion of all suicidal deaths (0.69%), the current series is slightly lower than data reported previously (approximately 1%).2,9 The proportion of cases in which death was certified as 'smoke inhalation' (40%) in this suicide series is lower than that for all fire fatalities. 1°-13 Burns have been reported to be the cause of over 70% of fire related suicides. 2 It is suggested that this difference is derived primarily from a definitional problem, i.e. what constitutes suicide by fire? In this series, any suicide in which the fire brigade were involved has been included. However, other series refer to selfimmolation or suicide by burning. 2,14 Furthermore, the observed difference in causes of death is possibly also attributable to variations in death certification rather than in the actual mechanism of death. It is not possible to identify precisely and with certainty the factors which 'caused' an individual to commit suicide unless these are described in a suicide note. However, it is reasonable to note the associations with known risk factors at the time the person died. The association between unemployment and suicide is widely documented. 15,16 The four cases in this series in which the deceased had been receiving treatment for schizophrenia exhibited no other obvious precipitating factor. Schizophrenia has been associated with wilful fire-raising and suicide (and para-suicide) by burning. 9,14,1738Suicide by self-immolation has also been associated with other psychiatric disorders. 339-21 The victims who were reported as being 'depressed' in this series includes those exhibiting general dysthymia

and noted as being depressed by relatives or friends. The use of the term 'depression' therefore is not indicative of a clinical diagnosis. The one case associated with HIV is interesting because the precipitating factor was apparently the fear of infection rather than infection itself. 22,23 No overtly religious or political connotation to the death was observed in this cohort. Although suicide by self-immolation has been strongly associated with such motives, 4,2°,24-26our negative finding is consistent with other studies. 3,27The only act in the current series designed apparently for effect was a 39-year-old male who ignited himself in the presence of his former lover and her new male companion. Cases involving a man killing his spouse and/or children has been reported to be typical of a dyadic death? 8 The symbolic use of fire generally and the particular association between 'revenge' and fire-related actions has been explored elsewhere. 19,29 It was not possible to investigate adequately the relationship between acute drug use and suicide by fire in this series because of the low proportion of cases in which toxicology for drugs was performed. This is an important omission in the data and it is desirable that drug screens are performed routinely in all cases in which suicide is suspected. The nature of this series means that the implications for suicide prevention are limited. Clearly there is a need for continued vigilance within hospitals - the hospital suicide in this series illustrates that selfimmolation can be initiated quickly and without the use of accelerants. The suicides associated with relationship break-ups were apparently impulsive in nature and in the absence of any predictive device prevention is not possible. Suicides associated with HIV testing might be prevented by the provision of adequate counselling before and after the test: this, of course, assumes that the individual makes contact with medical professionals. The low number of suicides by fire in any one population suggests that a multi-centre initiative should be established. The primary task of such a venture might be to establish a common definition of fire related suicide or self-immolation which would enable more direct comparisons of rates and precipitating factors to be made. REFERENCES

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