Networked Knowledge - Medical Issues
Diagnostics of Drowning Cases

Authors: Dr Robert N Moles and Bibi Sangha barrister

These notes on the difficulties associated with the diagnosis of drowning were submitted to the Medical Board of South Australia, and to the Solicitor-General of South Australia as part of the submissions on behalf of Mr Keogh

We are grateful to Associate Professor Tony Thomas and to Dr Harry Harding for their assistance with this report

Diagnostic difficulties

There are no autopsy findings pathognomic of drowning. (Derrick Pounder, Lectures in Forensic Medicine, University of Dundee)

The lungs are characteristically over-inflated and heavy with fluid. However, this is not invariable and, when present, is not distinguishable from “fluid on the lungs” (pulmonary oedema seen in heart failure, drug overdose and head injury). (Derrick Pounder, Lectures in Forensic Medicine, University of Dundee).

There are no universally accepted diagnostic laboratory tests for drowning. (Derrick Pounder, Lectures in Forensic Medicine, University of Dundee).

These observations and experimental results underline the belief that a thorough autopsy should be carried out on every suspicious fatality in the bathtub even if first examination at the scene does not reveal any severe injury. (Schmidt and Madea at p145)

The examination of a body, discovered in a bath, must first of all determine whether the person died from drowning or from one of a range of causes of sudden natural death, or as a result of fatal poisoning. (Devos, Timperman and Piette at p194)

Finally, there is the actual drowning itself, but even here diagnostic difficulties abound.  …  In fact, there may be nothing obvious at necropsy apart from non-specific signs of immersion. (Editorial BMJ at p1340)

The diagnosis of drowning is complicated by the fact that there are no specific tests to prove drowning and there are no autopsy findings that in and of themselves prove drowning. (Dix, Graham and Hanzlick at p 21).

What aggravates these situations is the fact that no reliable tests permitting an unequivocal diagnosis of drowning are available. (Spitz and Fisher at p 353)

At autopsy, the lungs of a drowning victim commonly resemble those seen in deaths associated with severe pulmonary edema, as in cases of arteriosclerotic heart disease. (Spitz and Fisher at p 353)

The presence of pulmonary edema is of no help, as it might be present in drug overdoses, heart failure or drowning. (at p 406)

Drowning in the bath tub poses a considerable medicolegal problem. In our experience such drownings occur only if unconsciousness is brought about by disease (epilepsy, heart disease, etc) or after consumption of alcohol and / or drugs. (Spitz and Fisher at p 354)

Many corpses are recovered from water, but not all have drowned. Of those that have drowned, pathological proof is often difficult or even impossible to obtain. The autopsy diagnosis of drowning presents one of the major problems in forensic medicine, especially when there is delay in recovering the victim. (Saukko and Knight at p 395)

It [the froth] is similar in appearance to the oedema of left ventricular failure that is commonly seen in deaths from cardiac disease such as hypertension… (Saukko and Knight at p 402)

Positive evidence of drowning is often lacking and difficult to obtain even after a complete autopsy accompanied by ancillary aids. … the actual fact of drowning, as opposed to sudden death from cardiac arrest, is often impossible to prove. (Plueckhahn at p204.18)

No excuse can be made for any final examination of suspected “drowned” persons that fails to be a well-planned and complete autopsy examination including the head and neck. (Plueckhahn at p204.19)

Proper interpretation of the findings also requires the skills of an experienced pathologist, supported by adequate histological, biochemical and toxicological analysis of material taken at autopsy. (Plueckhahn at p205.19)

Histology. Should intravascular fat globules be demonstrated by special staining of lung and brain tissue it may be very useful supplementary evidence in establishing whether a “drowned” person was alive or not on submersion or when trauma was inflicted. (Plueckhahn at p 206.20e)

Is Death due to Drowning?

It is obvious, therefore, that it is impossible to say to any degree of certainty in some cases whether death was due to drowning or not and the practitioner is advised to refuse to give a decided opinion on insufficient grounds. If there are no signs of any other cause of death it is for the legal authority to make the assumption that the body taken from the water in such conditions was drowned. (Smith and Fiddes at p 268)

Bodies may be found after immersion in either fresh or salt water, but proof that death was due to drowning may constitute one of the most difficult problems in forensic medicine. (Camps and Cameron at p 315)

If the circumstances of death are known, the diagnosis of drowning will not present any difficulty. However, when a body is found in water and no circumstantial details are available of how it got there, the case may pose a difficult problem. In some cases, the diagnosis of drowning cannot be established for lack of definite signs; hence one has to draw conclusions on the basis of exclusion of other causes of death. In such situations every detail of the case must be considered with an open mind. (Fatteh at p154)

A fatal accident in the bathtub is frequently associated with an epileptic attack, an episode of acute coronary insufficiency and alcohol or drug intoxication. In such a death also minor injuries from a fall may be present. The body should be examined for injection marks and electrical burns. Past history of the decedent must be reviewed. (Fatteh at p155)

In addition to the evaluation of the internal injuries, the role of any natural disease condition in the collapse of the person found in the water should be properly assessed. Adequate microscopic and toxicological studies must be made. Sections of the lungs from drowning cases show evidence of acute emphysema with rupture of many of the alveoli. The analyses for alcohol should be done routinely. Analyses for drugs that the decedent was known to be using also should be a part of the investigation especially in a bathtub death and in suicide. (Fatteh at p159)

It is imperative that all available information concerning the circumstances of drowning is given to the pathologist prior to autopsy. (Polson, Gee and Knight at p427)

There are numerous cases of drowning where there is nothing characteristic at autopsy on naked-eye examination and, in fact, if the circumstances were not known that the body had been taken from the water, it would be very difficult in some cases for the pathologist to decide that the death was due to drowning. (Bowden at p294)

It will be clear from this that the pathological investigation of such cases is difficult and it must be agreed that this is an area of forensic practice in which the pathologist is unable to give an opinion which is sufficiently positive as to satisfy the requirements usually demanded in a medico-legal investigation. (Mant at p301)

It emerges that the investigation must be carried out without any preconceived idea that because a body has been found in water drowning is the cause of death. The examinations must, therefore, include a detailed examination of the clothing and the body for marks.
The internal examination, in addition to a search for the findings associated with drowning, must include detailed microscopy to determine the nature, extent and stage of antecedent disease. (Mant at p301)

A diagnosis of drowning cannot be made without a complete autopsy and full toxicologic screening, histologic analyses of all organs including the lungs, and the diatom test. The diagnosis of drowning cannot be based solely on the circumstances of the death, nonspecific anatomic findings, and the results of biologic analyses. (Payne-James, Busuittil and Smock at p250)

In the absence of eyewitness accounts, it is difficult if not impossible to differentiate the cases in which the victim falls into the water already dead from those in which death occurs after the fall into the water - Knight 1991. (Payne-James, Busuttil and Smock at p 250)

No pathognomic findings have been found in other organs during autopsy related to drowning. (Payne-James, Busuttil and Smock at p 252)

Diagnosis of exclusion

The diagnosis of drowning following circulatory collapse is made on the basis of exclusion. (Devos, Timperman and Piette at p194)

At autopsy, there are no pathognomic findings to indicate the diagnosis of drowning. The diagnosis is based on the circumstances of the death, plus a variety of nonspecific anatomical findings. … A diagnosis of drowning cannot be made without a complete autopsy, especially without a complete toxicological screen, because this is a diagnosis of exclusion. If individuals are found in water and all other causes of death have been excluded, they are presumed to have drowned. (DiMaio and DiMaio at p 402)

It is obvious, therefore, that it is impossible to say to any degree of certainty in some cases whether death was due to drowning or not and the practitioner is advised to refuse to give a decided opinion on insufficient grounds. If there are no signs of any other cause of death it is for the legal authority to make the assumption that the body taken from the water in such conditions was drowned. (Smith and Fiddes at p 268)

Irrespective of natural disease or injury, some persons who die after falling into water do not drown, in the accepted physiological sense. The great problem for the pathologist is that, even in true drowning, there may be no autopsy signs, especially if any appreciable delay has occurred before recovery or autopsy, or both. Therefore, it may be difficult or impossible for him to say whether a death is a true drowning, or one from the non-drowning mechanisms. All that can then be offered is that death was due to “immersion” – and even then such a diagnosis is usually one reached by exclusion of natural disease, trauma or toxic conditions, using hearsay circumstantial evidence to arrive at a pathological diagnosis. This is why drowning and immersion deaths present one of the most difficult problems for the forensic practitioner. (Saukko and Knight at p 399)

If the circumstances of death are known, the diagnosis of drowning will not present any difficulty. However, when a body is found in water and no circumstantial details are available of how it got there, the case may pose a difficult problem. In some cases, the diagnosis of drowning cannot be established for lack of definite signs; hence one has to draw conclusions on the basis of exclusion of other causes of death. In such situations every detail of the case must be considered with an open mind. (Fatteh at p154)

A fatal accident in the bathtub is frequently associated with an epileptic attack, an episode of acute coronary insufficiency and alcohol or drug intoxication. In such a death also minor injuries from a fall may be present. The body should be examined for injection marks and electrical burns. Past history of the decedent must be reviewed. (Fatteh at p155)

In addition to the evaluation of the internal injuries, the role of any natural disease condition in the collapse of the person found in the water should be properly assessed. Adequate microscopic and toxicological studies must be made. Sections of the lungs from drowning cases show evidence of acute emphysema with rupture of many of the alveoli. The analyses for alcohol should be done routinely. Analyses for drugs that the decedent was known to be using also should be a part of the investigation especially in a bathtub death and in suicide. (Fatteh at p159)

Conclusion

No forensic pathologist would deny the fact that there is not one pathognomonic autopsy finding indicative of the diagnosis of drowning. The best chance of making the diagnosis of drowning is when the body is not affected by putrefaction. In every case the diagnosis of drowning should be made by the evaluation of the findings suggestive of drowning, the circumstantial details and the exclusion of other causes of death. (Fatteh at p164)

It emerges that the investigation must be carried out without any preconceived idea that because a body has been found in water drowning is the cause of death. The examinations must, therefore, include a detailed examination of the clothing and the body for marks.
The internal examination, in addition to a search for the findings associated with drowning, must include detailed microscopy to determine the nature, extent and stage of antecedent disease. (Mant at p301)

A diagnosis of drowning cannot be made without a complete autopsy and full toxicologic screening, histologic analyses of all organs including the lungs, and the diatom test. The diagnosis of drowning cannot be based solely on the circumstances of the death, nonspecific anatomic findings, and the results of biologic analyses. (Payne-James, Busuttil and Smock at p250)

If an individual is found in water and other anatomical causes of death were excluded, the individual is presumed to have drowned, …  (Payne-James, Busuttil and Smock at p250)

If the anatomic and toxicologic observations are equivocal, the opinion that death resulted from drowning is merely presumptive, and death is attributed to drowning only because autopsy failed to disclose some other cause. Obviously, it is preferable that a diagnosis of death from drowning (indeed, from any cause) be based on positive rather than on negative evidence, but this desirable state of affairs does not always obtain. (Adelson at p 558)

Full Medical History of Deceased is Essential

As in all examinations of patients, one must have a medical history. In the case of the forensic pathologist, the “patient” is unable to render this history. Therefore, the history must be obtained by either the medical examiner or police investigators. This history must be known before the autopsy begins. (DiMaio & D DiMaio at p 547)

A fatal accident in the bathtub is frequently associated with an epileptic attack, an episode of acute coronary insufficiency and alcohol or drug intoxication. In such a death also minor injuries from a fall may be present. The body should be examined for injection marks and electrical burns. Past history of the decedent must be reviewed. (Fatteh at p155)

It is necessary, however, on all occasions to consider all the available information. (Polson, Gee and Knight p426)

6.2.1 Approach to the autopsy

Wherever possible, and particularly where it is relevant to the investigation, the forensic pathologist should have access to the medical history of the deceased before the autopsy is commenced. Where such records are not forthcoming, the pathologist will need to decide whether it would be sensible for the autopsy to be postponed until the information becomes available. (UK Code of Practice at 6.2)

22. All available information should be gathered, read and considered before commencing any post-mortem examination. (Plueckhahn at p 118)

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