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Many drowning deaths in Sri Lanka preventable: Study 

14 Mar 2022

  • Forensic academics make recommendations based on Kalubowila Hospital post-mortem reports 
BY RUWAN LAKNATH JAYAKODY  A little less than half of the drowning deaths studied at the Colombo South Teaching Hospital in Kalubowila could have been prevented as drowning is a preventable type of death under injury prevention strategies.  This finding was made in an original research paper on the “Characteristics of cases of fatal drowning at a tertiary care hospital in Sri Lanka” authored by H.T.D.W. Ariyarathna and E.L.P.A. Jayathilaka (both attached to the Sri Jayewardenepura University’s Medical Sciences Faculty’s Forensic Medicine Department) and published in the Galle Medical Journal 26 (3) in September 2021. “Deaths that ensue from the submergence of a person in water are considered as drowning. When the manner or circumstance of death is considered, drowning could be accidental, suicidal, homicidal, or unascertained. Some victims who drown manage to survive without any ill effects. The events of drowning may cause immediate death, delayed death, morbidity or even brain death resulting in a vegetative status. Drowning incidents are just grouped under injuries in the Indoor Morbidity and Mortality Record (IMMR), the latter which classifies injuries and diseases according to the International Statistical Classification of Diseases and Related Health Problems. Moreover, an agreed terminology in relation to drowning is essential in order for an effective comparison to be done (the World Health Organisation’s [WHO] “Final global report on drowning”). According to the WHO, drowning is easily preventable. Even global estimates are considered by the WHO to be significantly lower than the real incidence of drowning,” Ariyarathna and Jayathilaka mentioned. Ariyarathna and Jayathilaka also observed that some cases of fatal drowning are easily preventable while the post-mortem examinations showed that most of the deaths were unwarranted. However, there is no national database on deaths due to drowning in Sri Lanka.  A descriptive study was therefore carried out by Ariyarathna and Jayathilaka retrospectively, based on the reports of the post-mortem examinations performed at the Colombo South Teaching Hospital from September 2015 to September 2020, and included the post-mortem records of all confirmed cases of deaths due to drowning.  A total of 4,804 post-mortem examinations were performed during the five-year period, out of which, 65 deaths were due to drowning, accounting for 1.35% of all the post-mortem examinations. There were 58 males and seven females with a male to female ratio of eight to one. There were only four near drowning incidents where the victims died only following admission, whereas all the other victims were dead on admission (61 – 93.8%). The mean (average) age was 42.7-years. The highest number of deaths was reported in the age category of above 70-years followed by the age category of 16-years to 20-years. The highest number of deaths (38 – 58.5%) was reported in the above 30-years age group. Most deaths were accidental (41 – 63.1%), followed by suicides (14 – 21.5%). One death was a homicide (1.5%), involving a 43-year-old male. Nine deaths (13.8%) could not be definitively categorised and therefore they were classified as “unascertained”. There was a considerable gap between the males and females in accidental deaths (male to female ratio being 7.3 to one) and suicidal deaths (male to female ratio being 6.1 to one). No females were found in the categories of homicide and unascertained drowning deaths. It was ascertained by the time of death that 20/30.8% victims had consumed alcohol whereas 30/46.2% had not. In 14/21.5% cases, the alcohol consumption status before drowning could not be ascertained. The sea was the commonest location for drowning (30 – 46.2%) followed by wells (16 – 24.6%) and other locations which included swimming pools, lakes, ponds, and water ditches (19 – 29.2%). Twenty-eight/43.1% bodies showed the presence of typical froth while 35/53.8% did not show such froth. There was no significant association between the medium of drowning and the presence of froth around the nose and mouth. Ante-mortem and/or post-mortem injuries were noted in 24/36.9% at sites such as the face, chest, abdomen, and limbs. No injuries were noticed in 41/63.1% bodies. When considering the ante-mortem injuries, the face was the commonest region affected (nine – 56.25%) followed by the limbs (five – 31.25%), whereas in post-mortem injuries, the limbs (eight – 44.44%) were the commonest body region affected followed by the face (five – 27.77%). Injuries seen over the abdomen were solely of post-mortem in origin and this was the body region that had been minimally affected when considering all the injuries. When considering each body region and the comparison between the ante-mortem and post-mortem injuries, the face received more ante-mortem injuries compared to post-mortem injuries (nine versus five), and the limbs received more post-mortem injuries compared to ante-mortem injuries (eight versus five). There had been four/6.2% live admissions following the incident of immersion/near drowning, and they succumbed to the injuries later. At the time of the post-mortem examination, mild/moderate putrefaction and severe putrefaction were noticed in 19/29.2% and eight/12.3% cases, respectively. Of the 65 cases studied, 26/40% were identified by the respective forensic pathologists as preventable deaths while 12.3% deaths were identified as unpreventable. According to the WHO, drowning is considered as the third leading cause of death due to unintentional injury worldwide and it is responsible for 7% of all injury-related deaths. Drowning-related incidents are handled under the category of preventable injuries in Sri Lanka, and it is also included as a type of unintentional injury, per the Health Ministry. “Drowning is a major public health problem and thus an effective preventive mechanism is mandatory. To achieve this, it should include the study of all cases of drowning in a given country, detailing the underlying causes and/or risk factors. That task is impossible when there are no accepted definitions with consistent coding that can be compared locally and internationally. Therefore, a proper data analysis system is needed to be implemented in our country.” The WHO defines drowning as “death by asphyxia due to submersion in a liquid medium” while near drowning is defined as “immediate survival after asphyxia due to submersion”. The latter may end up with, as noted in A. Busuttil and J. Keeling’s “Paediatric forensic medicine and pathology”, either survival or death. “There are no accurate statistics in Sri Lanka on drowning-related deaths. Some victims do not warrant any hospital admission though they actually experienced imminent threat. The rest of the patients may need hospital admissions. Out of those, a proportion of patients may not experience any ill effect and they recover without any residual damage (live discharges). Another proportion of patients may experience permanent brain damage resulting in delayed death. In a real sense, those findings are not counted as cases of drowning. This partially explains why the real number of victims who experienced drowning may be far more than the figures reported in hospital statistics.” Ariyarathna and Jayathilaka are of the view that not only the fatal cases but also these types of cases too need to be analysed in order to study its epidemiology and the underlying factors for drowning and that it is the responsibility of the forensic pathologists to highlight such important aspects to the stakeholders. The IMMR is prepared by using statistics provided by Government hospitals, but according to the Annual Health Statistics, around 60% of deaths are encountered in non-hospital settings. Ariyarathna and Jayathilaka’s study revealed that fatal drowning constitutes a little more than 1% of the total post-mortem examinations conducted at the institution during the given period. There were two peaks observed in the age distribution. According to Ariyarathna and Jayathilaka, the first peak in the 16-20-year age group could have been due to the reason that young males tend to consume alcohol and swim during their leisure time. The second peak may be due to suicides and accidental causes with advancing age. The WHO states that nearly 60% of all drowning deaths were “below the age of 30 years”. In Ariyarathna and Jayathilaka’s sample, only 27/41.54% were below 30 years. The number of children below 15 years was five/7.7%. Ariyarathna and Jayathilaka’s findings indicated the lowest drowning rate being in the five-years to 14-years age group.  A male preponderance was observed by Ariyarathna and Jayathilaka. In “A cross country analysis of drowning in Sri Lanka: 2001 to 2006 and 2009”, B. Matthews, R. Birch, M. Jayawardena, D. Mathew, A. Nanayakkara, S. Wiyayaratne and S.D. Dharmaratne revealed the same to be four to one.  “The manner/circumstances of death play a significant role in deaths due to drowning. All manner of death are commoner in males with a considerable gap between females.” “The epidemiology of drowning in low and middle income countries: A systematic review” by M.D. Tyler, D.B. Richards, C. Reske-Nielsen, O. Saghafi, E.A. Morse, R. Carey and G.A. Jacquet also showed that accidental death is the most common category in all instances. P. Paranitharan, W. Perera, S. Lakmal, D. Priyanath, T. Senanayake and M. Kumari’s “Deaths following drowning in Sri Lanka – A retrospective study” revealed that the commonest circumstance was accidental (57.6%), while suicide amounted to 22%, and the circumstances were unascertained in 20.3% and no homicides were reported. “Colombo is a city where the sea is closer to any given point and it could well be the most common site for drowning.” Out of the accidental deaths, two deaths were due to drowning in swimming pools where a five-year-old boy had accidentally drowned while participating in a wedding ceremony with his parents, and a 30-year-old male accidentally drowned after alcohol consumption. Ariyarathna and Jayathilaka highlighted the preventability of these two deaths. “With a four-sided fence and parental supervision, the death of this five-year-old child could have been prevented. Related laws concerning swimming pool safety have not been implemented in Sri Lanka yet.” The United States Centres for Disease Control and Prevention has identified various predisposing factors related to swimming pool deaths and injuries. Subpar swimming skills, absence of four-sided fencing around the pool, the lack of supervision, alcohol use and seizure disorders are some of these risk factors. Ariyarathna and Jayathilaka recommended that stakeholders implement strict laws at swimming pool facilities in Sri Lanka along with four-sided fencing along with the employing of a lifeguard/pool attendant.  Ariyarathna and Jayathilaka identified four cases with some survival time following the initial incident of drowning. Such cases are termed as cases of near drowning. The majority had reportedly died during the incident. One case had been treated for a day in a ward and the other three had only been treated for a few hours. “The management of cases of near drowning may need ventilation.”  The cause of death of drowning is ascertained by excluding all other possible causes. The presence of typical froth is considered more or less a specific feature in drowning. Ariyarathna and Jayathilaka found typical froth in a little less than half of the deaths. Fine, white, coarse and copious froth is considered as a significant finding in relation to deaths due to drowning. No significant difference was found in the presence of froth depending on the medium of drowning.  Alcohol consumption before death was identified in approximately one third of the individuals while 30 individuals had not consumed any alcohol. According to the Health Ministry, human behaviour is identified as a key risk factor for the occurrence of drowning. Paranitharan et al. had found that 21% had consumed alcohol before accidental drowning. “Decomposition is a frequent occurrence observed in dead bodies that are recovered from the water.” Only 41.5% of the bodies showed putrefactive changes. A dead body recovered from the water may show injuries either in the forms of ante-mortem or post-mortem injuries. According to A. Farrugia and B. Ludes’s “Diagnostic of drowning in forensic medicine”, traumatic injuries are not common in subjects with a history of drowning. P. Fornes, G. Pépin, D. Heudes and D. Lecomte’s “Diagnosis of drowning by combined computer assisted histomorphometry (the measurement of the shape or form of a tissue) of lungs with blood strontium (chemical element) determination” emphasised that differentiation between ante-mortem and post-mortem injuries is difficult at times due to a multitude of reasons with the absence of well defined criteria being one such reason. Histology also plays an important role in the differentiation of ante-mortem and post-mortem injuries. In non-putrefied bodies, the microscopic examination of body parts may contribute to differentiate ante-mortem drowning from post-mortem drowning. The histological examination of lung tissues may provide clues. In addition to trauma, the state of dress, the effort made to rescue the body, adiposity (the condition of having much or too much fatty tissue in the body), the post-mortem contact of the body against surfaces, animal predation and the amount of air in the lungs and bowels before drowning, are a few factors that determine, as elaborated in E.J. Armstrong and K.L. Erskine’s “Investigation of drowning deaths: A practical review”, the nature of post-mortem injury patterns. The Sri Lanka Life Saving organisation, the Life Saving Victoria organisation in Australia and the Australian High Commission in Sri Lanka have declared 3.5 deaths per 100,000 people in Sri Lanka from 2016 to 2018.  The respective forensic pathologists have mentioned that 40% of the cases could have been prevented while 12.3% deaths have been identified as unpreventable. According to the latest reports available in Sri Lanka, about 800 Sri Lankans die annually due to drowning and it is the second leading cause of deaths due to unintentional injury. In conclusion, Ariyarathna and Jayathilaka made several recommendations: i) the relevant age groups should be addressed in order to prevent premature and unnecessary deaths; ii) vulnerable areas of the sea should be secured with much wider publicity; iii) strict rules and regulations should be imposed to prevent swimming pool-related deaths; iv) the underlying causes and risk factors contributing to the deaths of children by drowning should be studied; v) the contribution of alcohol consumption to drowning needs to be studied quantitatively or by performing blood tests in every possible case; vi) the exact burden of deaths due to drowning should be identified with more emphasis in order to develop accurate databases representing the whole country; vii) a compulsory and detailed reporting system of all the deaths due to drowning with possible risk factors should be implemented and a national database needs to be maintained; and viii) cases of near drowning and live discharges following immersion incidents too need to be included in the drowning statistics of the country with uniform definitions, to be on par with the international nomenclature.


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