Deaths at Sea: Los Angeles,2000-2011

Abstract

With the expansion of the shipping and cruise ship industries, there is a need for a more complete understanding of the mortality risks at sea. We conducted a retrospective review of shipboard deaths coming under the jurisdiction of the County of Los Angeles Department of Coroner during the years 2000-2011. Sixty-one shipboard deaths were identified, of which 24 (39%) were among crew, and 37 (61%) were among passengers. Among both crew and passengers, there was a prominence of deaths due to cardiovascular disease. Also prevalent were accidents due to blunt trauma, accidents involving ethanol or medications, and suicides. The identification of multiple potentially preventable deaths after onset of symptoms at sea underscores the need for further improvements in maritime telemedicine, crew medical capability and long-distance evacuation.

Keywords

Forensic pathology Coroners and medical examiners Death investigation Autopsy Mortality

Introduction

World seaborne trade increased from 5.98 billion tons loaded in 2000, to 8.41 billion tons in 2010 (1). Worldwide, 19.2 million passengers were carried on cruise ships in 2011. This total of passengers carried worldwide is estimated to increase to 22.4 million in 2015 (2). With this expansion of the shipping and cruise ship industries, there is a need for a more complete understanding of the mortality risks at sea, in order to design interventions to reduce those risks in the future.

The Port of Los Angeles is situated on San Pedro Bay, 20 miles south of downtown Los Angeles. As measured by container traffic, it is the busiest port in the United States and the 16th busiest port in the world (3, 4). The Port of Los Angeles is the site of the World Cruise Center, which handled 1.2 million passengers in 2008 (5).

We present the experience of the County of Los Angeles Department of Coroner with shipboard death occurring among passengers and crew.

Materials and Methods

The County of Los Angeles Department of Coroner covers a population of 9.8 million. Between

January 1, 2000 and December 31, 2011, 55,459 autopsies were performed. Cases were identified retrospectively based on the following criteria: (a) the death occurred on board a sea-going ship (cargo ship, oil tanker or cruise ship); (b) the death falls under the jurisdiction of the Los Angeles Department of Coroner. Evaluation of each case included review of investigator's report, autopsy report, toxicology findings, and reports of any additional studies or consultations including histopathology, microbiology, neuropathology and radiology.

Results

A total of 61 shipboard deaths were identified in the 12-year interval from 2000 through 2011. Of these, 24 (39%) were crew, and 37 (61%) were passengers. Full autopsies were performed on 96% of the crew, and 30% of the passengers. There was one stowaway counted with the passengers. Crew and passengers and are treated separately in the subsequent analyses.

Among the crew, 23 (96%) were male, and the mean age was 46 years. The manner of death was natural in a majority (62.5%), with accident being the next most common manner (21%) (Table 1). Almost all natural deaths (14 out of 15) were due to cardiovascular disease, with the other natural death due to a previously undiagnosed acute leukemia. There was a death of undetermined manner due to myocardial infarction of undetermined etiology, in which multiple subendocardial microinfarctions were seen, with no significant coronary artery disease, and with special stains negative for microorganisms and toxicology negative aside from a blood ethanol of 0.03 gm%. This case was given an undetermined manner of death due to the possibility of a toxic etiology for the microinfarctions. There were three industrial accidents: a longshoreman crushed while loading containers on a ship, a seaman crushed when steel plates fell on him on board a ship, and a seaman thrown by a wave against a deck fixture. Additional accidents consisted of a medications overdose (propoxyphene and cyclizine), and a case of phlegmonous gastritis in a man with probable alcohol withdrawal and excessive water intake with electrolyte imbalance. The three suicides among crew consisted of two hangings, and one person who died of an incised wound to the wrist. In one of the suicides, the crewman was found hanging in his cabin after ten days of abdominal complaints and vomiting, and ruptured appendicitis was seen at autopsy. In the other suicidal hanging, the crewman had reportedly been fired for being under the influence of alcohol while on duty prior to being discovered hanging in his cabin. All crew suicides occurred in single-person cabins.

Table 1

Characteristics of Crew Members

Case	Age	Sex	Cause of Death	Manner	Full Autopsy?
C1	50	M	Ruptured vertebral artery aneurysm	Natural	Yes
C2	60	M	Hypertrophic heart disease	Natural	Yes
C3	46	M	Atherosclerotic heart disease	Natural	Yes
C4	36	M	Myocardial infarction	Natural	Yes
C5	39	M	Lymphoid leukemia	Natural	Yes
C6	29	M	Incised wound of wrist	Suicide	No
C7	46	M	Dilated cardiomyopathy	Natural	Yes
C8	41	M	Idiopathic cardiomyopathy	Natural	Yes
C9	63	M	Blunt force injuries	Accident	Yes
C10	52	M	Atherosclerotic heart disease	Natural	Yes
C11	57	M	Atherosclerotic heart disease	Natural	Yes
C12	38	M	Phlegmonous gastritis^*	Accident	Yes
C13	56	M	Atherosclerotic heart disease	Natural	Yes
C14	56	M	Atherosclerotic heart disease	Natural	Yes
C15	37	M	Craniocerebral trauma	Accident	Yes
C16	31	M	Blunt injuries of chest	Accident	Yes
C17	36	M	Hanging	Suicide	Yes
C18	31	F	Medication overdose	Accident	Yes
C19	57	M	Atherosclerotic heart disease	Natural	Yes
C20	50	M	Atherosclerotic heart disease	Natural	Yes
C21	53	M	Atherosclerotic heart disease	Natural	Yes
C22	64	M	Hanging^†	Suicide	Yes
C23	51	M	Atherosclerotic heart disease	Natural	Yes
C24	32	M	Acute myocardial infarction	Natural	Yes

Probable ethanol withdrawal and excess water intake as contributing factors

†

Ruptured appendicitis as a contributing factor

Among the passengers, 22 (59%) were male, and the mean age was 65 years. The manner of death was natural in a majority (84%), with accident being the next most common manner (8%) (Table 2). Most natural deaths (29 out of 31) were due to cardiovascular disease, with additional causes attributed to chronic obstructive pulmonary disease (COPD) and appendicitis. One case of atherosclerotic heart disease had colonic diverticular hemorrhage as a contributing factor. The accidents consisted of a fall from one deck to another, and two involving ethanol intake as a contributing factor (blood ethanol levels of 0.38 and 0.33 gm%). There was one suicidal hanging in a cabin shared with a spouse, and one suicidal fall from one deck to another. There was one case of undetermined manner, in which a woman with atherosclerotic heart disease was found submerged in a bathtub. The stowaway died from atherosclerotic heart disease.

Table 2

Characteristics of Passengers

Case	Age	Sex	Cause of Death	Manner	Full Autopsy?
P1	44	M	Atherosclerotic heart disease	Natural	Yes
P2	41	M	Atherosclerotic heart disease	Natural	Yes
P3	70	F	Ruptured acute appendicitis	Natural	yes
P4	52	M	Atherosclerotic heart disease	Natural	NO
P5	36	F	Blunt force injuries	Accident	yes
P6	76	M	Atherosclerotic heart disease	Natural	no
P7	83	M	Blunt force injuries	Suicide	NO
P8	59	M	Atherosclerotic heart disease	Natural	NO
P9	88	F	Atherosclerotic heart disease^*	Undetermined	Yes
P10	34	M	Hanging	Suicide	YES
P11	62	M	Atherosclerotic heart disease	Natural	NO
P12	71	M	Atherosclerotic heart disease	Natural	NO
P13	73	M	Atherosclerotic heart disease	Natural	NO
P14	61	M	Atherosclerotic heart disease	Natural	NO
P15	69	F	Atherosclerotic heart disease	Natural	NO
P16	78	F	Atherosclerotic heart disease	Natural	NO
P17	70	M	Atherosclerotic heart disease†	Natural	YES
P18	73	M	Atherosclerotic heart disease	Natural	NO
P19	89	M	Atherosclerotic heart disease	Natural	NO
P20	60	M	Atherosclerotic heart disease‡	Accident	NO
P21	76	F	Atherosclerotic heart disease	Natural	NO
P22	51	M	Atherosclerotic heart disease	Natural	YES
P23	64	M	Idiopathic cardiomyopathy	Natural	NO
P24	78	F	Atherosclerotic heart disease	Natural	NO
P25	57	F	Chronic obstructive pulmonary disease	Natural	NO
P26	75	F	Atherosclerotic heart disease	Natural	NO
P27	67	M	Atherosclerotic heart disease	Natural	NO
P28	69	M	Atherosclerotic heart disease	Natural	NO
P29	59	F	Intracerebral hemorrhage	Natural	NO
P30	74	F	Atherosclerotic heart disease	Natural	NO
P31	54	M	Atherosclerotic heart disease	Natural	YES
P32	69	M	Atherosclerotic heart disease	Natural	NO
P33	56	F	Hypertensive heart disease‡	Accident	YES
P34	57	M	Atherosclerotic heart disease	Natural	NO
P35	69	F	Atherosclerotic heart disease	Natural	Yes
P36	73	F	Atherosclerotic heart disease	Natural	No
P37	74	F	Atherosclerotic heart disease	Natural	No

Found submerged in bathtub

†

Colonic diverticular hemorrhage as a contributing factor

‡

Ethanol intake as a contributing factor

Examining only those 11 passengers on whom full autopsies were performed reveals similar results. Among the fully autopsied passengers, six (55%) were male, and the mean age was 56 years. The manner of death was natural in a majority (64%), with accident being the next most common manner (18%) (Table 2). Most natural deaths among fully autopsied passengers (six out of seven) were due to atherosclerosis.

In the majority of cases, death was pronounced at sea, with only four (17%) of the crew and two (5%) of the passengers pronounced in port. With the exception of the stowaway on a cargo ship, all passengers died on cruise ships. Among crew, 15 (62%) were on cargo ships, five (21%) were on cruise ships, and four (17%) were on oil tankers.

In six cases, death may have been prevented had the decedent been able to receive a higher level of care in a timely manner. Of these potentially preventable deaths after onset of symptoms or injury, four (67%) were among crew (Table 3). The time interval from the onset of symptoms/injury until death (“Time with symptoms” in Table 3) was determined from ship-board documentation (such as a medical chart or ship's log) describing the course of the decedent's illness or injury. Full autopsies were performed on all six of these cases. The crew members suffered from a previously undiagnosed acute leukemia, accidental blunt injuries, a suicidal hanging following a ruptured appendicitis, and a myocardial infarction due to coronary artery disease. The crew members were either on cargo ships or an oil tanker, none with medical doctors on board. Medical evaluation via radio was obtained for all crew members. In the case of the blunt injuries (due to being thrown against a deck fixture by a wave), a language barrier between the ship crew and the nearest country's naval authorities appeared to have impeded the early stages of rescue planning. Both deaths among passengers occurred on cruise ships with on-board medical doctors, but required a higher level of care (for ruptured appendicitis and a gastrointestinal bleed). In all cases, evacuation was not possible by the time the severity of the decedent's condition became apparent. Retrospective review of their reported symptoms, however, reveals that significant time intervals passed between the first reported symptom and the time of death, ranging from seven hours to ten days.

Table 3

Potentially Preventable Deaths

Case	Doctor on Board?	Synopsis	Time with Symptoms
C5	No	Acute leukemia; medical evaluation by radio	30 hours
C16	No	Blunt injuries; medical evaluation by radio; language barrier during rescue planning	30 hours
C22	No	Suicide by hanging after 10 days of abdominal complaints with vomiting; medical evaluation by radio; ruptured appendicitis at autopsy	10 days
C24	No	Acute myocardial infarction; medical evaluation by radio	7 hours
P3	Yes	Ruptured appendicitis	47 hours
P17	Yes	Atherosclerotic heart disease and diverticular bleeding	19 hours

Discussion

We report 61 shipboard deaths coming under the jurisdiction of the County of Los Angeles Department of Coroner during the years 2000-2011. We find a predominance of deaths due to cardiovascular disease. Also prevalent are accidents due to blunt trauma, accidents involving ethanol or medications, and suicides. Although we did not identify deaths due to contagious disease in this study, such deaths (for example, due to ship borne gastroenteritis) would be considered Coroner's cases (written communication, David Kim, MD, October 1996 involving a passenger who had norovirus gastroenteritis diagnosed by a Los Angeles County Medical Examiner/Coroner autopsy). The identification of multiple potentially preventable deaths after the onset of symptoms underscores the need for further improvements in maritime telemedicine, crew medical capability and long-distance evacuation.

Our retrospective study is limited by the availability and quality of data from cases handled up to 12 years previously. While almost all crew cases received full autopsies, only about 30% of passenger cases received full autopsies. Autopsies were less likely to performed on passengers if there was no suspicion of foul play during investigation, and if there was a strong clinical impression of a natural cause of death in some-one older than 60 years. Crew tended to be autopsied regardless of circumstances in part because of the additional regulatory and epidemiologic scrutiny accorded occupational fatalities. This special interest in occupational fatalities, with the attendant unique risks that crew members face, explains why crew and passengers are analyzed separately in this study. As discussed in the results above, the passenger cases with full autopsies showed general characteristics similar to those from the whole passenger group.

The shipboard population presenting to the Port of Los Angeles does not comprise all seafaring groups equally. In particular, the mortality in the fishing industry is not represented in the deaths described in this study.

Our finding that 37.5% of deaths among crew were non-natural is similar to that reported by Oldenburg et al. (6), who found that non-natural deaths comprised 40-50% of all crew deaths in a review of three studies of occupational mortality among European seafarers on merchant ships. The occurrence of three industrial accidents by blunt force injury among the 24 crew deaths in our study speaks to the risks of the occupation, and the need for ongoing vigilance to prevent accidents during movement of heavy objects and during deck activities in heavy seas. Accidents among seafarers are substantially more common when compared to those among other workers, with a relative risk of 24 found in a study of workers in Great Britain (7).

The risk of natural death is also increased among seafarers. A study of over 24,000 Danish merchant seafarers found an increased risk for natural death (standardized mortality ratio (SMR) 1.13, 95% confidence interval (CI): 1.02-1.24) when compared to the general population, with a particularly increased risk among non-officer deck and engine room crew (SMR 1.60, 95% CI: 1.39-1.84), and a notably higher risk of alcoholism among all seafarers (SMR 2.82, 95% CI: 1.77-4.26) (8). The absence of a “healthy worker effect” among seafarers has led to the suggestion that they have generally more risky lifestyles apart from their more hazardous work environment (8 –10).

In addition, there is an increased likelihood of suicide among seafarers when compared to the general population, as found in the above-men-tioned study by Hansen et al. (SMR 1.77, 95% CI: 1.41-2.20) (8) and in another study showing an over two-fold increase in the suicide rate among non-officer Finnish crew members (11). Our finding of suicides in three of 24 (12.5%) crew deaths is consistent with the proportion of suicides found among deaths of Polish merchant seafarers (10.2%) (12). Risk factors for suicide that have been identified among seafarers include comorbid mental illness, substance abuse, isolation, work and family stress, and a recent change of ships (11, 12). Reduction in suicide risk may be achievable by psychological screening at the start of voyages to identify and intervene with those found to be at high risk.

The preponderance of death due to cardiovascular causes among both crew and passengers indicates the potential to reduce mortality with improved or novel interventions. Improvement in prevoyage cardiovascular risk assessment and preparation has been suggested both for passengers (13) and crew (14, 15). Sudden changes in the behavior of passengers while on cruises, with respect to alcohol consumption, dietary indulgence and physical activity may place some at particularly high risk (13). On-board interventions to steer passengers away from such behaviors may be appropriate. There is also an opportunity for long-term cardiovascular risk modification among crew while on board, includ-ing dietary changes, smoking cessation, moderation of alcohol intake, increased physical activity (with possible addition of exercise rooms) and blood pressure control (14, 16).

While standards for ship medical facilities and staff have been established for many cruise ships (17), the capabilities on cargo and tanker ships are more limited. Improved maritime telemedicine capabilities hold promise for all ships at sea, but these will not supplant the need for improved medical knowledge and training among seafarers to enable them to handle emergencies when there is no doctor aboard, with or without a telemedicine link (18).

Footnotes

The authors, reviewers, editors and publication staff do not report any relevant conflicts of interest.

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