Introduction

According to the definition accepted within the last decade, drowning is a process resulting in a respiratory function disorder that occurs when sinking down under water [1–4]. Drowning constitutes 0.07 % of unintentional deaths [1]. This means about 500,000 drowning deaths occur per year all over the world [2, 4, 5]. Therefore, drowning is a major public health problem worldwide [3, 6, 7]. According to the 2008 United Nations Children’s Fund (UNICEF) report, 22 % of children all over the world die in traffic accidents, and 17 % die from drowning [8]. According to some authors, drowning is the third most common cause of unintentional death among children and young people [3, 5, 9–11]. Drowning has been reported as the top-ranked accidental death category of the pediatric age group in Southeast Asia and the Western Pacific regions [1]. In addition, drowning is one of the major causes of death in childhood in countries such as Australia, the United States, and Japan [1]. There are also a large number of drowning cases in European countries. According to several publications, the reason for this high rate is that many immigrant families come from low-income countries [8, 12].

Age and gender are the most important risk factors in drowning cases [1, 3, 5–7, 9, 10, 13, 14]. Children under 5 years of age and the male gender were the most important risk factors in many studies [3, 5–7, 11, 15–18]. Drowning is more common in younger age groups because of the child’s carelessness and negligent supervision, according to some studies [13, 17–20]. The increase in public pools and pools in residential areas has led to an increase in deaths in the pediatric age group [6, 10, 11, 17, 21–24]. There have also been reports of children dying while taking a bath [13, 17, 23]. Other risk factors include the improper use of locations such as seas, lakes, ponds, or pools; low socioeconomic status; low level of education; the presence of diseases, such as epilepsy; alcohol and drug abuse in older age groups; and swimming in unusual places [1]. The correlation between knowing how to swim and the risk of drowning is not clear [2].

Drowning originates as an accident, suicide, or murder. Deaths with an accidental origin are common in childhood in the 0–18 age group. Drowning deaths are important when researching deaths with an accidental origin [25–29]. Based on our experience, the origin is difficult to determine when an autopsy has not been performed in a drowning death. The autopsy must be done carefully and must be evaluated with the crime scene and legal investigations. A dead body removed from the water is different from a drowning case; a body in the water does not necessarily mean a drowning has occurred. Opinions on the cause of death and origin should be avoided when only an external examination of the dead, and not an autopsy, has been conducted.

In our study in Aydın between 2002 and 2012, we evaluated pediatric drowning cases for which our department conducted a postmortem examination and an autopsy. We determined the characteristics and compared them with domestic and foreign studies.

Materials and methods

In Aydın, Adnan Menderes University, Faculty of Medicine, Department of Forensic Medicine is the only authorized forensic unit that serves the entire city. All autopsies are performed by the department staff under the supervision of the district attorney.

In Aydın, autopsies are not performed at a headquarter facility. After the crime scene has been investigated by the gendarmerie and/or the police, the body is taken to the nearest hospital morgue, where the autopsy is performed. The first authorities to see the corpse and perform the examination are general practitioners. Forensic experts perform an autopsy at the hospital to which the body has been transported. An autopsy is performed by forensic experts in all cases if the cause of death was not successfully determined with an external examination.

This study used the deceased examination and autopsy reports from 2002 to 2012. In the 0–18 age group, 255 autopsies were performed by the Adnan Menderes University Department of Forensic Medicine. A total of 39 drowning cases in the 0–18 age group were analyzed regarding age, gender, cause of death, origin, accident scene, and the month in which the death occurred. Statistical analyses were conducted using Statistical Package for the Social Sciences (SPSS) 14.0 for Windows. p < 0.05 was considered statistically significant.

Results

In Aydın, from 2002 to 2012, the cause of death was asphyxia in 66 (25.9 %) out of the 255 cases in the 0–18 age group for whom autopsies were performed at the University department. The 39 drowning cases constituted 15.3 % of all cases and 59 % of all z cases.

Of the drowning cases, 33 (84.6 %) were male, and 6 (15.4 %) were female. The female-to-male ratio was 5.5:1. The youngest was a 1-year old, and the oldest was 18-year old. The average age was 9.08 years. In the distribution of age groups, drowning was most common in the 0–4 age group (33.3 %), followed by the 10–14 age group (25.6 %), the 15–18 age group (25.6 %), and the 5–9 age group (15.3 %). The age groups and the distribution according to gender are given in Table 1.

Table 1 Age groups of cases and distribution according to gender
Full size table

In this study, drowning was most common during the summer (56.4 %) and spring (43. 5 %). The most common months were July (17.9 %) and May (15. 4 %). The scene of the accident was within the city limits in 28 cases (71.8 %), the district in 9 cases (23.1 %), and a village or town in 2 cases (5.1 %).

The crime scene investigations, autopsy findings, and judicial investigation showed all of the cases were accidents; none were murders or suicides. No abnormality was determined in the medical histories either; all 39 children were confirmed healthy.

No traumatic lesions were found according to the autopsy findings. Traumatic findings such as abrasions and ecchymosis were observed on the external examination; however, these lesions did not affect the death of the subjects, and were caused by falls, friction, and drifting underwater. In the internal examinations, evidence drowning (white froth, fine froth, waterlogged lungs) was found in the trachea, bronchia, and lungs in all cases, and 31 cases (79.4 %) had water in the stomach and duodenum.

When we look at the distribution according to the scene of the accident, 43.5 % occurred in an irrigation channel, 15.3 % in a river, 12.8 % in the sea, 10.2 % in a pool, and 7.7 % in a lake or pond. In addition, 1 child drowned in a water barrel, 1 in a water hole in a pit, 1 in a barrage, 1 in a water hole in a basement, and 1 who had growth retardation and epilepsy drowned in the bathroom while bathing. There was no significant difference statistically between the age groups of the cases and the scene of the accident (p > 0.05), as shown in Table 2.

Table 2 Scene of the accident in drowning cases according to the age range
Full size table

Irrigation canals are used to irrigate cultivated areas. The canals vary in length, depth, and structure. There are no protective barriers around the canals, and most are very close to residential areas. Sometimes, canals sometimes even cross residential areas.

Our study revealed that 17 children (43.5 %) were with their friends, 18 (46.1 %) were alone, and 4 (10 %) were refugees who drowned when their boat sank. One child who drowned while alone had been left at home under his older brother’s supervision, and another child drowned while his parents were working in the fields. In two cases in which an autopsy was not performed, the cause of death was determined with an external examination and crime scene and judicial investigations. In both cases, eyewitnesses were present during the drowning accident. In most of the cases (64.1 %, n = 25), the children drowned while they were swimming or cooling off in the water. Eight children (20.5 %) drowned in pools or barrels used to provide water for animals or irrigation. Two children drowned while playing in puddles and four children drowned when their refugee boat sank.

According to the autopsy findings, there were external traumatic findings such as ecchymosis, abrasions, and lacerations in 16 cases (41 %); however, no traumatic lesions in the viscera and vessels were found.

In 89.7 % of the cases, the victim died at the scene of the accident. An autopsy was performed in 37 of the cases (94.8 %), a histopathological examination was performed in 4 (10.2 %), a toxicological examination was performed in 15 (38.4 %), and alcohol, opiates, and narcotics agents were screened in 26 (66.6 %). All drowning cases were determined to be accidental.

Samples for histopathological, toxicological, and drug examinations are taken during the autopsy by the forensic expert, if the cause of death cannot be completely determined with an autopsy when there is a suspicious situation or an allegation of substance and/or alcohol use in the history of the event. In this study, the histopathological samples did not reveal any type of pathology. In addition, the toxicological and alcohol–drug tests were normal.

Discussion

Asphyxia was determined to be the cause of death for 35 % of the cases with an accidental origin. Drowning cases constituted the largest portion of the asphyxia cases with an accidental origin (82.9 %). In a study conducted by Tokdemir et al. [26] in Elazig that examined forensic death cases in the 0–18 age group, drowning ranked second among non-natural causes of death (19.1 %). Yüksel et al. [15] evaluated preschool childhood deaths in Ankara and found the cause of death in 30 cases (21.4 %) was drowning. Drowning ranked third at a rate of 10.7 % in a study performed by Canturk et al. [27] in Istanbul. Drowning in Konya constituted 2.6 % of all cases, respectively [28]. Blunt trauma was followed by drowning, in a study performed in Adana [29]. Drowning caused 20.1 % of childhood deaths with an accidental origin in Istanbul [30].

Drowning was suspected or claimed in 11 % of cases in a study that evaluated autopsies in Adana [31]. This ratio was 7.26 % in another study performed in a larger series in the same area. The rates were 5.5 % for Ankara, 3.2 and 3.3 % for Diyarbakir, and 7.1 % for Edirne in different studies [32–34]. Drowning was also present in two studies that examined external examinations and autopsy series performed in Sivas [35, 36].

It was reported that 13.03 % of the 7,551 drowning cases in Spain [37] and approximately 2.7 %, or 314 of the 11,655 cases, drowned in water in a study conducted in India [38] based on autopsies. It was reported that 168 of the 197 bodies found in the water had drowned in a study covering an 8-year period from 1997 to 2004 in Greece [39]. It was reported that out of all the 1,590 bodies taken out of the water, 1,499 (94.3 %) drowned in a large study that covered the 23-year period between 1976 and 1998 in Finland [40].

In our study, drowning was the most common cause of death (33.3 %) in the 0–4 age group. This was followed by the 10–14 (25.6 %) age group, the 15–18 (25.6 %) age group, and the 5–9 (15.3 %) age group. In studies in which forensic death cases in the 0–18 age group were examined, drowning was the most common cause in the 0–5 and 15–18 age groups in a study performed by Tokdemir et al. [26] in Elazig. Drowning was the most common cause of death in the 15–18 and 10–14 age groups in a study performed by Yayci et al. [30] in Istanbul. In a study that evaluated drowning cases in the emergency department in Adana [25], 9.8 % of the cases were in the 0–4 age group, 46.3 % were in the 5–15 age group, and all the cases who died (9.7 %) were under the age of 15 years. It has been reported that 14.1 % of all drowning cases were under the age of 15 years in a study in the 2002–2006 period in Mazandaran, Iran [41]. In Matlab, Bangladesh [19], 21 % of the deaths of children aged 1–4 years were due to drowning. Children and young people under the age of 15 are considered at-risk groups worldwide. Our findings in terms of age distribution agree with the rates for developing countries in studies performed in Turkey and abroad. Drowning cases are observed at any age in Turkey but are more frequent under the age of 40. This finding supports the view that drowning ranks first among the causes of unnatural child deaths [19, 29, 31, 34, 38, 42–46].

Of all cases in our study, 33 (84.6 %) were male. The male-to-female ratio was 4:1 for the Çukurova region and 3:1 for Diyarbakir in studies conducted in Turkey [7, 34]; 85.6 % of the cases were male and 14.4 % were female in a large study [33]. Turgut et al. [3] observed that in Turkey, for all age groups, 84 % of all drowning cases were male. Although the male-to-female ratio varies according to the year, it was 2.3–8.7:1 in India [38], 2.7–11.3:1 in Singapore [42], 4.16:1 for the adults in the United States of America (Sacramento, CA) [46], 6.6:1 in New York [47], 2.31:1 in Denmark [48], 4.76:1 in South Africa (Cape Town) [49], and 6.5:1 in Iran [10]. In similar studies, 65 % of the drowning cases in Greece [39], 78.98 % in Spain [37], and two out of three in Sweden [12] were male. Our results support the findings that the probability of an unnatural death is lower for women, and the male gender is a risk factor in drowning [43, 44].

In our study, 17 of the cases (43.5 %) were in the spring, and 22 cases (56.4 %) were in the summer. Shetty et al. [37] reported that an increase in drowning occurs during the rainy season when the water is higher in rivers, lakes, and ponds. In many studies performed in Turkey and abroad, the frequency of drowning increased in the summer months, in line with our findings. The need to cool off due to the warm weather seems to be a natural cause underlying this relationship [5, 10, 34, 38, 43].

The scene of the accident in the drowning cases was an irrigation channel in 43.5 % of the cases, a river in 15.3 %, a sea in 12.8 %, a pool in 10.2 %, and a lake or pond in 7.69 %. There was also 1 drowning in a water barrel, 1 in a water hole in a pit, 1 in a barrage, 1 in a water hole in a basement, and 1 case who had growth retardation and epilepsy who drowned in the bathroom while bathing. A study in Alanya/Antalya examined the patients taken to the emergency department due to drowning: 65.62 % of the drowning cases took place at sea, 28.12 % in a pool, and 6.3 % in fresh water. Another study in Samsun (the Black Sea Region) reported that 74.5 % of the cases occurred in saltwater [4, 43]. A study that examined asphyxiating death cases in Edirne reported that the scene of the accident was a river in 73.1 % of the 40 cases who drowned in water [50].

In studies performed in different countries, different distributions are observed in terms of the scene of the accident. In a study in Greece [39], all 197 cases drowned in the sea. The sea ranked first in Singapore [42], rivers are ranked first in Nigeria [51], ponds were the highest in Iran [10], wells, ponds, and rivers were ranked first in India [38], and swimming pools were ranked the highest in the United States [46], especially for children. Turkey is an agricultural region, and there is no seacoast inland; this is why irrigation channels are ranked first, unlike other regions.

An autopsy was performed in 37 of the cases (94.8 %). Autopsies are not performed in the cases of the presence of reliable witnesses and/or the person rescued from the water was alive when taken to the hospital. Many studies performed in Turkey reported that an autopsy does not need to be performed in drowning cases that are considered accidental; only an external examination is performed, which happens in other accidental deaths [31, 35, 36]. Most studies are based only on autopsy reports; external examinations are not covered; thus, the rates do not reflect the real numbers [31]. An autopsy was performed for only 13 % of those who drowned, while an external examination was performed for 87 %. In a study performed by the public prosecutor of Diyarbakır, death certificates were studied [34]. The higher autopsy rate we found reflects the positive effect of the active participation of experts at the Adnan Menderes University Department of Forensic Medicine.

Conclusion

In Turkey, Lifesaving Regulations of the Turkish Underwater Sports Federation have been published to prevent drowning [52]. These regulations are mainly about providing first aid in the event of drowning and appeal to the tourist regions [52]. Unfortunately, there is no other written program. As a team, we agree on the need for these precautions; however, the same level of seriousness and discipline is also required when it comes to applying them.

When we look at the precautions regarding drowning in Aydın, unfortunately, the necessary importance has not been given, the necessary work has not been performed to apply the existing rules, and sectors have not collaborated to prevent the deaths caused by drowning. As of December 2014, irrigation canals are still open, the necessary precautions in places such as wells or small pools in houses have not been taken, and no sanctions are applied to people who swim in dangerous locations and disregard the warning signs that state the danger of swimming there. In addition, the opinions of forensic experts who have autopsy data have not been solicited regarding drowning in Aydın. Our study revealed that 25 % of the children could have been saved, if only the necessary precautions had been taken around open water areas (buckets, barrels, pools used for irrigation or to provide water for the animals, wells) in private residences. In the short term, children should be taught in schools about the danger of irrigation channels and imams should inform the public about irrigation channels during the Friday sermon.

Drowning is a preventable cause of death. Precautions such as teaching children how to swim; monitoring them while they swim; increasing the number of public pools; preventing swimming in open canals and puddles; placing warning signs near places such as seas, dams, and dam reservoirs; educating families; inspecting vehicles used for transportation in places such as seas and lakes; using life jackets; building protective structures such as barriers around pools; organizing education programs in the printed and visual media; and prohibiting the use of alcohol during swimming and water sports have been recommended in studies. The same level of seriousness and discipline is also required when it comes to applying these precautions. Everybody, especially authorities, should reconsider drowning prevention programs, and they should have different strategies for different age groups and cultures.