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Objective: Vehicle materials developments raise concerns about new patterns of vehicle fire toxic gas emissions. This study aimed to describe toxicologic components in a recent material of fatal car crashes on Swedish roads in which the vehicle caught fire and compare the results to a previous material. Methods: Retrospective registry study. All fatal car crashes with fire in Sweden 2009–2018 were extracted from the Swedish Transport Administration’s In-Depth Studies Database and compared with an earlier study of the time period 1998–2008. Results: A total of 79 crashes and 94 fatalities were included. Carbon monoxide (COHb) blood levels >10% were found in 13 cases. Hydrogen cyanide (HCN) blood levels 0.1–1.7 µg/g were found in 10 cases. In 31 of the cases the person had a blood alcohol level (BAC) >0.2‰, which is the legal driving limit in Sweden. A total of 15 people died due to burn injuries and 2 individuals died due to toxic gas emissions without any other fatal traumatic injury. Total number of deaths in fire-related crashes halved from 181 (1998–2008) to 94 (2009–2018) but the percentage of fatalities in burning vehicles was unaltered (5% vs. 6%). The proportion of fatalities with HCN in the blood increased from 2% between 1998–2008 to 10% during 2009–2018 (p = 0.006). The age of the car involved in a crash increased by 0.26 years per calendar year (p = 0.001). Conclusions: The proportion of fatalities with measured levels of HCN in the blood has increased. Eleven of the 15 burn injury fatalities had high levels of alcohol, HCN, or COHb, possibly contributing to an inability to leave a burning vehicle. Faster rescue brought by improved specific education and training of ambulance and rescue services personnel may be of future importance, as may on-scene antidote administration and revised regulations of vehicle flammability.

The crash of a coach with 58 occupants at 100 kmph revealed the danger of covering ditch areas with sharp stones 5–20 cm in size. Stones and dirt were sprayed into the coach compartment resulting in serious injuries and death. Road safety works need to address this factor in the future.

The loss of human lives and body injuries due to post-crash fires, either by smoke inhalation or due to burn injuries, are unfortunately not uncommon. The literature indicates that fire events related to crashes are still a significant problem. The increased combustible load in newer vehicles is an important factor to be taken into account for the fire safety, as well as their potential to release toxic fumes while burning. Trends indicate that the survivable collision energy will continue to increase, and, at the same time, the probability of post-crash fires rises with the collision energy. This means that the occupants of a vehicle may probably survive a high-energy collision but might sustain severe injuries or death due to a post-collision fire. This work reports a literature and interview study about post-crash fires including statistics on the causes and dynamics of post-crash fires in road vehicles based on the literature, crash and incident reports, as well as on interviews with medicine specialists. Results from this study indicate that fires in vehicles which originated by a collision event are a problem that remains to be solved.

OBJECTIVES: Increased demands are placed on emergency services and their role and ability to act in incidents in challenging environments, for example, road tunnels. Collaboration between officers from emergency services (fire brigade, police and ambulance services) is important for an effective rescue effort. In Gothenburg, Sweden, a position as a senior ambulance officer (SAO) within the emergency medical services (EMS) has been introduced to support the regular force during major incidents. The aim of this paper was to explore the perceptions and experiences of the SAO's new management role in challenging incidents, such as those occurring in road tunnels. DESIGN: A qualitative interview study. SETTING: The study was carried out from February to June 2019 in Gothenburg, Sweden, which is a municipality with several road tunnels and a population of approximately 580 000 people. SAOs collaborate with the corresponding function within the police and fire brigade, both having senior officers at major incident sites. PARTICIPANTS: Twelve SAOs. METHODS: The study used semistructured interviews. The collected data were analysed using qualitative content analysis. RESULTS: According to SAOs' experience, prehospital medical management included not only leadership, but also planning, training and indepth knowledge of, for example, tunnel environments. Furthermore, SAOs adopted an encouraging and teaching role for their colleagues. SAOs' responsibilities also included proactive planning together with the fire brigade and police, which was regarded as enhancing interorganisational collaboration. An overall theme emerged which the SAOs described as 'A new holistic approach to EMS leadership and management'. CONCLUSIONS: The participants considered that the new SAO role not only seems to improve the prehospital medical management, but also makes the EMS command structure during challenging incidents symmetrical with the fire brigade and police command structure. The implementat

Objective: Identify factors of preparedness for peer first response to underground mining emergencies with injured victims. Design: Cross-sectional questionnaire study of Swedish underground mineworkers. Setting: Seven out of nine Swedish underground mines. Participants: A total of 741 mineworkers out of 1022 (73%) participated in this study. Interventions: None. Outcome measures: Level of preparedness for emergencies with injuries in underground mines. Results: Three factors influenced the preparedness of mineworkers for a peer first response: (1) familiarity with rescue procedures during emergencies with injuries; (2) risk perception of emergencies with injuries and (3) experience of using self-protective and first aid equipment. Mineworkers who believed that they knew how to handle emergencies with injuries (OR 1.30, 95% CI 1.22 to 1.38) and those who were trained in the use of self-protective and first aid equipment (OR 1.19, 95% CI 1.07 to 1.32) considered themselves to be better prepared for a peer first response than those who were unfamiliar with the rescue procedures or who had not used self-protective and first aid equipment. However, mineworkers who rated the risk for emergencies with injuries as high considered themselves to be less prepared than those who rated the risk as low (OR 0.95, 95% CI 0.91 to 0.98). Conclusion: This study identified three factors that were important for the peer-support preparedness of underground mineworkers. More research is needed to adapt and contextualise first aid courses to the needs of underground peer responders.

Händelsen: Tågolyckan inträffade på morgonen den 22 februari 2012 när ett lokaltåg okontrollerat körde in i stoppanordningen i slutet av perrongen på Once station, i centrala Buenos Aires. Hastigheten var mellan 20 och 27 km i timmen, men stoppet var så kraftigt att vagn nummer två trängde sex meter in i vagn nummer ett. Sammanlagt skadades cirka 850 personer varav 51 avled, de flesta omkom i samband med att de två första vagnarna klämdes ihop. Bidragande faktorer till att så många skadades var, ett överfullt tåg av äldre modell, som var dåligt underhållet, och kördes av en organisation med låg säkerhetsmedvetenhet. Händelsen visar att en masskadesituation kan uppstå även vid låga hastigheter. Räddningsinsatsen var omfattande: ett hundratal ambulanser, tre helikoptrar och mer än 500 räddningsarbetare engagerades för att omhänderta skadade och fördela dem mellan huvudstadens 13 akutsjukhus. Beredskapen i Buenos Aires var god vid denna händelse, tack vare genomförda risk- och sårbarhetsanalyser, övningar och utbildningsinsatser. Den argentinska akutmedicinska responsorganisationen och sjukhusen arbetade i stor utsträckning enligt samma katastrofmedicinska principer som i Sverige. Händelsen kunde därför analyseras utifrån ett svenskt perspektiv. Erfarenheter: Sverige har varit relativt förskonat från tågolyckor med många svårt skadade. Däremot har tillbuden ökat kraftigt och järnvägssystemet är idag slitet och överbelastat. Det finns därför anledning att studera inträffade tågolyckor i världen för att dra lärdom av internationella erfarenheter av olika skadebegränsande faktorer som kan vara av betydelse för svensk katastrofmedicinsk beredskap. Det går att dra flera lärdomar ifrån tågolyckan på Once-stationen. Nedan redovisas ett antal sammanfattande slutsatser från händelsen med relevans för den svenska beredskapen: • Det finns en risk att händelser med många svårt skadade kan inträffa även vid låga hastigheter. • Tågens konstruktion, utformningen av koppel och deforma

Rationale: There is a lack of long-term follow-up studies focused on injured and uninjured survivors’ experiences of the recovery process after major traffic crashes. Aim/objective: To explore survivors’ experiences of long-term physical and psychological consequences and recovery five years after a major bus crash. Methodological design and justification: A qualitative design was used to explore experiences in a 5-year follow-up study. Research methods: Participants were 54 survivors of a bus crash with 56 survivors and six fatalities. Telephone interviews were analyzed with qualitative content analysis. Results: The theme overarching the categories is “visible and existential marks in everyday life” and it represents the range of the crash’s influence in the survivors’ lives. The first category, “health consequences in daily life,” has four subcategories covering quick recovery, suffering in daily life, distress in traffic situations, and long-term pain. Described reasons for quick recovery among survivors were previous crisis experiences, traveling alone, being uninjured, and not being exposed to traumatic impressions. For the other survivors, being reminded of the crash caused disturbing reactions, such as sweating, anxiety, and flashbacks. Survivors avoided going by bus if they could. A group of the injured survivors were still suffering from limiting and painful injuries. The second category, “oneself and social connection,” has three subcategories that include self-awareness, impact on relationships, and connectedness. Survivors developed a stronger bond to their significant other or separated from their partner within the first couple of years. Friendships and a sense of connectedness among survivors were sources of long-lasting comfort and support. Conclusion: There is a need for more information about disruptive long-lasting consequences, such as travel anxiety, and available treatments. Initially, health-promoting connectedness can be facilitated by treat

OBJECTIVE: Underground mining is associated with obvious risks that can lead to mass casualty incidents. Information about such incidents was analyzed in an integrated literature review. METHODS: A literature search (1980-2015) identified 564 modern-era underground mining reports from countries sharing similar occupational health legislation. These reports were condensed to 31 reports after consideration of quality grading and appropriateness to the aim. The Haddon matrix was used for structure, separating human factors from technical and environmental details, and timing. RESULTS: Most of the reports were descriptive regarding injury-creating technical and environmental factors. The influence of rock characteristics was an important pre-event environmental factor. The organic nature of coal adds risks not shared in hard-rock mines. A sequence of mechanisms is commonly described, often initiated by a human factor in interaction with technology and step-wise escalation to involve environmental circumstances. Socioeconomic factors introduce heterogeneity. In the Haddon matrix, emergency medical services are mainly a post-event environmental issue, which were not well described in the available literature. The US Quecreek Coal Mine incident of 2002 stands out as a well-planned rescue mission. CONCLUSION: Evaluation of the preparedness to handle underground mining incidents deserves further scientific attention. Preparedness must include the medical aspects of rescue operations.

Objective The aim of this study was to explore physical and mental consequences and injury mechanisms among bus crash survivors to identify aspects that influence recovery. Methods The study participants were the total population of survivors (N=56) from a bus crash in Sweden. The study had a mixed-methods design that provided quantitative and qualitative data on injuries, mental well-being, and experiences. Results from descriptive statistics and qualitative thematic analysis were interpreted and integrated in a mixed-methods analysis. Results Among the survivors, 11 passengers (20%) sustained moderate to severe injuries, and the remaining 45 (80%) had minor or no physical injuries. Two-thirds of the survivors screened for posttraumatic stress disorder (PTSD) risk were assessed, during the period of one to three months after the bus crash, as not being at-risk, and the remaining one-third were at-risk. The thematic analysis resulted in themes covering the consequences and varying aspects that affected the survivors' recoveries. The integrated findings are in the form of four core cases of survivors who represent a combination of characteristics: injury severity, mental well-being, social context, and other aspects hindering and facilitating recovery. Core case Avery represents a survivor who had minor or no injuries and who demonstrated a successful mental recovery. Core case Blair represents a survivor with moderate to severe injuries who experienced a successful mental recovery. Core case Casey represents a survivor who sustained minor injuries or no injuries in the crash but who was at-risk of developing PTSD. Core case Daryl represents a survivor who was at-risk of developing PTSD and who also sustained moderate to severe injuries in the crash. Conclusion The present study provides a multi-faceted understanding of mass-casualty incident (MCI) survivors (ie, having minor injuries does not always correspond to minimal risk for PTSD and moderate to severe injuries

Objectives. To explore the perceptions and experiences of mining-, rescue service- (RS), and emergency medical service (EMS) personnel regarding how to handle incidents in an underground mine. Methods. Six focus-group interviews and 10 individual interviews were carried out with groups of mining-, RS and EMS personnel, who served the underground mining industry located in small municipalities in a sparsely populated area of northern Sweden. The transcripts of the interviews were analysed using qualitative content analysis. Results. The three groups mostly described experiences of minor incidents and announced a limited preparedness for handling major mining incidents. Collaboration was described as being difficult because of limited knowledge about the others’ responsibilities and capacities. Few non-mining personnel were trained, or prepared to fulfil their tasks in an underground environment, and some expressed that they would even refuse to go underground because of concerns for their own safety. Conclusions. There is a need for more collaboration and joint practices between and among the groups involved in rescue operations. Collaboration between mine- and RS personnel exists, but the EMS personnel is largely excluded from this interaction. Therefore, the EMS personnel are insecure about how to handle underground mining incidents. A closer collaboration between all organizations in preparing for mining incidents is emphasized, and would have positive effects on the rescue operation. Some experiences may also be used under similar circumstances, such as incidents in railway and road tunnels.

Denna sammanfattning redovisar de viktigaste resultaten och slutsatserna i delrapport 1 och 2. Dödsolyckor och allvarliga olyckor i arbetet har minskat kraftigt sedan 1950-talet i Sverige. I dag drabbas i genomsnitt 1 av 100 000 personer av en dödsolycka i arbetet och 1 av 500 personer av en allvarlig arbetsolycka.1 Nio av tio arbetsrelaterade dödsolyckor drabbar män. Dödsolyckor drabbar i högre grad äldre personer och mer än hälften av männen som omkom 2010-2014 var över 50 år. En delförklaring är att äldre får svårare skador än yngre om de utsätts för samma skadevåld och därmed ökar risken för en dödlig utgång. Fordonsrelaterade olyckor utgör ca hälften av alla dödsolyckor. Hälften av dem sker i vägtrafikområden och hälften i andra miljöer. Fallolyckor är en annan viktig orsak till dödsolyckor och då främst fall från en höjd. Många sådana olyckor inträffar inom byggverksamhet, och vår analys tyder på att byggställningar kan vara ett område för förbättringar för att undvika tekniska brister. Dödliga elolyckor drabbar framför allt äldre elinstallatörer, som sannolikt har långvarig yrkeserfarenhet. Det talar för att också personer med lång erfarenhet kan behöva återkommande utbildningar. Trädfällning är en annan betydande orsak till dödsolyckor, framför allt inom jord- och skogsbruk. En jämförelse av data ur registren för dödliga och allvarliga arbetsolyckor visar att det finns skillnader, bland annat när det gäller vem som drabbas och var skadan inträffar. Det innebär att register om allvarliga men icke dödliga skador ger begränsad information om vilka förebyggande åtgärder som är lämpliga mot dödsolyckor och var de ska sättas in. Vi har även analyserat uppgifter från dödsorsaksregistret i kombination med yrkesregistret. Resultatet ger ingen ytterligare information utöver den man kan få ur Arbetsmiljöverkets register. Vi har också studerat data från registret över personer som vårdats i sluten vård på sjukhus och kombinerat detta med data från yrkesregistret. Result, Fatal and serious occupational accidents have decreased in Sweden since the 1950s. Today, there is on average, about 1 fatal outcome of occupational accidents per 100 000 persons, and 1 serious accident per 500 persons.2 Nine of ten occupational accidents with fatal outcome 2010-2014 happened to men. Fatal accidents are more common among elderly people and more than half of the male victims were over the age of 50. Older people often suffer more severe injuries than younger people for the same trauma, which may have contributed to the observed higher death rate among mature and elderly persons. Accidents related to vehicles represented about half of all fatalities. Half of these happened on public roads in ordinary road traffic, and the other half happened in other places and under other circumstances than vehicle crashes. Falls, especially from higher level, were another significant cause of fatal accidents. Many such accidents occurred in the construction industry, and our analysis indicates that e.g. improvement of scaffolding could decrease the risk. Half of fatally injured electricians were older than 58 years with long occupational experience. This indicates that persons with long experience may also need repeated training and education. Cutting down trees was another important cause of fatalities, especially among older persons working within forestry and agriculture. Comparative data from registers of fatal and serious occupational accidents indicates differences in who had the accident and where the accident occurred. This means that a register of non-fatal accidents gives limited information about possible strategies for the prevention of accidents with fatal outcome. 2 A serious accident is an accident with at least 14 days sick absenteeism.12 Important conclusions are Fatal and serious occupational accidents are rare events with different causes. It is therefore difficult for organizations and working groups to learn from incidents in their own organizat

Background: The aim of this study was to survey the current equipment used for prevention, treatment and monitoring of accidental hypothermia in Swedish pre-hospital services. Methods: A questionnaire was sent to all road ambulance services (AS), the helicopter emergency medical services (HEMS), the national helicopter search and rescue service (SAR) and the municipal rescue services (RS) in Sweden to determine the availability of insulation, active warming, fluid heating, and low-reading thermometers. Results: The response rate was 77% (n = 255). All units carried woollen or polyester blankets for basic insulation. Specific windproof insulation materials were common in the HEMS, SAR and RS units but only present in about half of the AS units. Active warming equipment was present in all the SAR units, but only in about two-thirds of the HEMS units and about one-third of the AS units. About half of the RS units had the ability to provide a heated tent or container. Low-reading thermometers were present in less than half of the AS and HEMS units and were non-existent in the SAR units. Pre-warmed intravenous fluids were carried by almost all of the AS units and half of the HEMS units but infusion heaters were absent in most units. Conclusion: Basic insulation capabilities are well established in the Swedish pre-hospital services. Specific wind and waterproof insulation materials, active warming devices, low-reading thermometers and IV fluid heating systems are less common. We suggest the development and implementation of national guidelines on accidental hypothermia that include basic recommendations on equipment requirements.

Purpose: The purpose of this paper is to analyse factors influencing perceptions of preparedness in the response to terrorist attacks of operational personnel in Swedish emergency organizations. Design/methodology/approach: Data were collected using a questionnaire distributed to operational personnel from the police, rescue and ambulance services in eight Swedish counties; 864 responses were received and analysed. Findings: Three aspects of the perception of preparedness for terrorist attacks among Swedish emergency responders were studied: willingness to respond; level of confidence with tasks; and estimated management capability. Factors which positively influenced these perceptions were male sex, training in first aid and dealing with mass casualty incidents, terrorism-related management training (MT), table-top simulations, participation in functional exercises, and access to personal protective equipment (PPE); work experience was inversely related. Occupation in police or rescue services was positively associated with willingness to respond whereas occupation within the emergency medical services was positively associated with estimated management capability. Practical implications: These findings show that terrorism-related MT and access to PPE increase the perceptions of preparedness for terrorism among the emergency services, aiding judgements about investments in preparedness by crisis management planners. Originality/value: Limited research in disaster management and hazard preparedness has been conducted in a European context, especially regarding terrorism. Little is known about aspects of preparedness for terrorism in Sweden, particularly from the perspective of the emergency responders., First published in theses in manuscript form., Preparedness for mass-casualty attacks on public transportation

The aim of this paper is to analyse and compare injuries and injury sources in pedestrian and bicyclist non-fatal real-life frontal passengercar crashes, considering in what way pedestrian injury mitigation systems also might be adequate for bicyclists. Data from 203 non-fatal vehicle-to-pedestrian and vehicle-to-bicyclist crashes from 1997 through 2006 in a city in northern Sweden were analysed by use of the hospitals injury data base in addition to interviews with the injured. In vehicle-to-pedestrian crashes (n = 103) head and neck injuries were in general due to hitting the windscreen frame, while in vehicle-to-bicycle crashes (n = 100) head and neck injuries were typically sustained by ground impact. Abdominal, pelvic and thoracic injuries in pedestrians and thoracic injuries in bicyclists were in general caused by impacting the bonnet. In vehicle-to-pedestrian crashes, energy reducing airbags at critical impact points with low yielding ability on the car, as the bonnet and the windscreen frame, might reduce injuries. As vehicle-to-bicyclist crashes occurred mostly in good lighting conditions and visibility and the ground impact causing almost four times as many injuries as an impact to the different regions of the car, crash avoidance systems as well as separating bicyclists from motor traffic, may contribute to mitigate these injuries.

Nio av tio arbetsrelaterade dödsolyckor drabbar män. Utifrån vår analys verkar det som att kvinnor och män har liknande risk att drabbas av en dödsolycka om förhållandena i arbetsmiljön är likartade. Dödsolyckor drabbar också i högre grad äldre personer än yngre, och mer än hälften av männen som omkom var över 50 år. En viktig delförklaring är att äldre får svårare skador och har högre risk för dödlig utgång än yngre om de utsätts för samma skadevåld. Fordonsrelaterade olyckor utgör ca hälften av alla dödsolyckor, och hälften av dem sker i vägtrafikområden. Det finns dock redan många aktörer som arbetar för att förebygga olyckor i trafiken, så aktörer inom arbetsmiljöområdet bör prioritera förebyggande åtgärder i andra miljöer. Olyckor i sådana andra miljöer utgör ca en fjärdedel av alla dödsolyckor. Fallolyckor är en viktig orsak till dödsolyckor och då främst fall från höjd. Många sådana olyckor inträffar inom byggverksamhet, och vår analys tyder på att tekniska brister i byggställningar kan vara ett område för förbättringar. Dessutom bör åtgärder riktas mot gruppen äldre elinstallatörer eftersom de förhållandevis ofta drabbas av dödliga elolyckor. Trädfällning är en annan betydande orsak till dödsolyckor, framför allt inom jord- och skogsbruk. En jämförelse mellan data ur registren för dödliga och svåra men icke-dödliga arbetsolyckor visar på stora skillnader ibland annat vem som drabbas och var skadan inträffar. Det innebär att register om svåra men icke-dödliga skador ger begränsad information om vilka förebyggande åtgärder som är lämpliga mot dödsolyckor och var de ska sättas in. Sammantaget visar vår analys att statistik över allvarliga arbetsrelaterade olyckor, baserat på sjukskrivningstid, har begränsat värde när det gäller att prioritera åtgärder för att förebygga arbetsrelaterade dödsolyckor. I registren finns fritextsvar som beskriver händelseförloppet för varje anmäld olycka. En textanalys av dessa beskrivningar kan ge värdefull kunskap, men det är någo

The rail-bound sector has become a preferred target of terrorist attacks because of its vulnerability, and the most frequent way to carry out these attacks has been the use of explosive devices.The aim of this study is to investigate the effectiveness of modelling detonation effects inside train carriages using explicit finite element techniques. The numerical simulations consider fluid-structure interaction phenomena and several parametric studies are conducted. Carriage damage and injuries to the passengers are examined. Displacements in the model of the carriage structure do not vary greatly for small changes of the charge size, its location, or by open doors. Changing charge size, the location of the detonation, and door setting however had significant impact on the risk of eardrum rupture and fatality. Comparison of the simulation and real life data demonstrate a good agreement between the real and calculated displacements of the carriage, whereas the risk of death and eardrum rupture is slightly higher in the calculations. The model presented can reproduce a reliable actual situation if more parameters that influence injuries of blast waves were considered., Supplement: 1, Preparedness for mass-casualty attacks on public transportation

BACKGROUND: The ambulance milieu does not offer good thermal comfort to patients during the cold Swedish winters. Patients' exposure to cold temperatures combined with a cold ambulance mattress seems to be the major factor leading to an overall sensation of discomfort. There is little research on the effect of active heat delivered from underneath in ambulance care. Therefore, the aim of this study was to evaluate the effect of an electrically heated ambulance mattress-prototype on thermal comfort and patients' temperatures in the prehospital emergency care. METHODS: A quantitative intervention study on ambulance care was conducted in the north of Sweden. The ambulance used for the intervention group (n=30) was equipped with an electrically heated mattress on the regular ambulance stretcher whereas for the control group (n=30) no active heat was provided on the stretcher. Outcome variables were measured as thermal comfort on the Cold Discomfort Scale (CDS), subjective comments on cold experiences, and finger, ear and air temperatures. RESULTS: Thermal comfort, measured by CDS, improved during the ambulance transport to the emergency department in the intervention group (p=0.001) but decreased in the control group (p=0.014). A significant higher proportion (57%) of the control group rated the stretcher as cold to lie down compared to the intervention group (3%, p<0.001). At arrival, finger, ear and compartment air temperature showed no statistical significant difference between groups. Mean transport time was approximately 15 minutes. CONCLUSIONS: The use of active heat from underneath increases the patients' thermal comfort and may prevent the negative consequences of cold stress.

Suicides by drowning have received limited attention by researchers. A recent finding that almost onethird of all drowning deaths in Sweden were classified as suicide instigated this study. We identified 129 cases of suicide by drowning in Northern Sweden and analyzed the circumstances and the psychiatric history prior to the suicide. Information was obtained from autopsy, police and medical records, as well as from the National Inpatient Register. One-third of the suicide victims had previously attempted suicide and half of the victims had been hospitalized due to mental health problems. One-third of these had left the hospital less than one week before the suicide. Alcohol and psychoactive drugs were present in 16% and 62% of the cases, respectively. A history of mental disorder and previous suicide attempt (s), especially by drowning, is an ominous combination necessitating efficient clinical identification, treatment and follow-up if a complete suicide is to be prevented., The study was supported by grants from the Kempe Foundation and the Section of Forensic Medicine, Umeå University. We are also indebted to the National Board of Forensic Medicine and the National Board of Health and Welfare for providing data for the study.