6 TSALIKIDIS AND OTHERS v. GREECE JUDGMENT Discussion 1. The position of the rope mark is more consistent with strangulation than hanging – in cases of strangulation the ligature mark, as it was here, tends to encircle the entire neck without deviation upward or downward, and almost invariable there is a gap where the rope suspends the body. Hanging marks are almost always higher on the neck than strangulation marks. The marks present here are more consistent with strangulation. 2. From the photographs I saw there was no evidence of hypostasis (accumulation of blood in the legs that is to be expected after a normal hanging). This argues strongly against hanging. ... 4. Perhaps more importantly, one expects to see some sort of soft tissue damage within the underlying neck. Injuries are present in at least 1/3 of hangings. No damage was seen within the neck, which is worrisome. The absence of soft tissue injury does not rule out hanging, but if it had been present, a much more convincing case for strangulation could have been made. 5. Damage to the lining of the great vessels in the neck is a frequent finding in strangulation, but that examination was never performed (in fact, no microscopic examination was performed). This means the autopsy was incomplete by U.S. and EU standards. 6. The colour of the face could only be described as normal; typically, victims of manual strangulation will have deeply congested haemorrhagic faces, but victims of hanging often have pale faces – in this particular instance the colour of the face is so normal that it almost appears that neither strangulation nor hanging occurred. 7. While adequate examination is not possible only from inspecting photographs, the knot used to anchor the rope appears quite complex. This might be expected if the deceased had nautical experience, but the family insists he did not. 8. Homicidal hanging is very rare, since it is very difficult for one person to hang another, unless of course they had been drugged first. The autopsy report says that blood and urine were tested for alcohol and that the results show the deceased had been drinking (post-mortem alcohol production of that magnitude does not occur that quickly). I think it would be very important to know if any other drugs were present. If testing was not done at the time of autopsy, exhumation and testing of the hair is still possible. The results, whether positive or negative, would be definitive. 9. The medical examiner commented on the presence of pulmonary oedema. Such may occur after hanging, but histological studies have shown that pulmonary oedema is much more common after strangulation. 10. There were no scratch marks on the neck, suggesting the deceased made no effort to claw the rope away from his neck. This is also consistent with his having been sedated. Discussion Obviously, there is no evidence of forceful strangulation and, in the absence of visible trauma, homicidal hanging would appear to be out of the question. The fact that there was minimal suspension does not rule out suicide. Having said that, the case has a number of disturbing features: (1) the autopsy was grossly inadequate, and even if signs of homicide had been present, they would have been missed; (2) the face was of normal colour – neither congested nor pale; this argues for death before hanging;