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Epidemiological aspects of explosion-related deaths in a civilian setting may bring comprehensive knowledge that is important for prevention efforts. This Swedish national study aimed to describe the extent of such deaths, circumstances and fatal injuries. Data, including all explosion-related deaths in Sweden from 2000 through 2018, were retrieved from the register of the National Board of Forensic Medicine. Among all 87 cases found, accidental deaths accounted for 62%, suicides for 21%, homicides for 7% and undetermined manner of death for the remaining 10% of cases. Most victims died on site. Adult males dominated in the study material, but explosions also killed four children. Explosives were most commonly involved in occupational blast deaths, suicides and homicides, followed by flammable gases and fluids. The incidence showed a significant decrease since the 1980s, based on the incidence rate from this study and a previous Swedish study (1979–1984). As already rare occurrences, blast-related deaths are challenging to prevent. Prevention efforts are needed to restrict the availability of explosives and focus on lowering the occupational risk for injury. In addition, child deaths must not be neglected. A vision of no fatalities is an appropriate goal for acting against explosion-related deaths in a civilian setting.

Prevention of firearm deaths and injuries is an important public health issue that may save human lives. The aim of this thesis was to investigate the epidemiology and attributes of accidental firearm fatalities in Sweden, and to provide a basis for further preventive measures. Data were obtained from the database of the National Board of Forensic Medicine, the National Patient Register, the Prescribed Drug Register, the Firearm Register, and from questionnaire responses.

All 48 accidental firearm fatalities that involved hunting in 1983-2008 were investigated (Paper I). The victims’ mean age was 50 years, 96% were males. During moose hunting, most victims were mistaken for game (41%), whereas during small game hunting, fatalities were mostly related to falls (31%) and improper weapon handling (15%). Hunters’ habits and attitudes towards preventive measures and their experience of firearm incidents were investigated through a questionnaire, which was sent to 1,000 hunters (Paper II). The response rate was approximately 50%. The mean age of the respondents was 54 years and females accounted for 5%. One quarter of the respondents stated that they had witnessed a firearm incident caused by another hunter, of which more than half suggested that improper handling of the weapon and inappropriate hunting strategies were the main causes of these events.

All 43 accidental non-hunting firearm deaths in Sweden 1983-2012 were investigated (Paper III). In 56% of cases, the fatality was caused by another person. Victims were mostly young males (mean age 25 years). The main cause of the incidents was human error. The majority of cases (63%) involved legal firearm. Most victims killed by illegal firearm (85%) were under the influence of alcohol and/or drugs at the time of death. Both the risk of being killed as a result of hunting (Paper I) and non-hunting accidental firearm injury (Paper III) decreased after the introduction of the mandatory hunter’s exam in 1985 (p < 0.001).

Firearm deaths in Sweden including 52 accidental fatalities and 3 cases with undetermined manner of death in 1987-2013, as well as 213 suicides and 23 solved homicides in 2012-2013, were studied (Paper IV). The number of firearm suicides was positively correlated to the number of licensed firearm owners. Legal firearm use predominated in firearm suicides and accidental deaths, illegal in firearm homicides. The majority of the shooters in accidental deaths and suicides had no registered visits to inpatient care or specialized outpatient care. Less than half (42%) of all suicide victims had had a health care contact due to mental health problems. Physician’s mandatory reporting to the police of patients deemed unsuitable for possessing a firearm license did not include any of the suicide victims and the shooters in accidental deaths.

This thesis confirmed that accidental firearm deaths are rare, and indicates that the firearm law changes in 1985 contributed to a decline of such fatalities. Human error was the main “cause” of the fatalities and future prevention measures should target improper weapon handling. Physician’s mandatory reporting to the police was suboptimal and barely contributed to the decline of accidental firearm deaths. If streamlined it may, however, represent an important prevention strategy in firearm suicides, claiming most lives among firearm deaths. A significant fraction of non-hunting fatalities, firearm suicides and homicides was associated with illegal firearm use, a fact calling for prevention issues targeting such firearm use.

In a setting with restrictive firearm laws, prevention of firearm deaths is challenging. Around 100 firearm suicides occur annually in Sweden, representing the most common manner of death from firearm use. In order to explore a possible correlation between firearm suicides and firearm availability, legality of firearm possession, and demographic and geographical factors, all firearm suicides in Sweden among adults during the years 2016–2017 were studied. Data were collected from the National Board of Forensic Medicine and the Swedish Police. In total, 221 firearm suicides were found. Most victims were male (99%) and half (49%) were ≥65 years old. Firearm suicide rates were positively correlated with firearm ownership rates in Swedish counties. Legal firearms (80%) and long-barreled firearms (76%) predominated in the overall material, but illegal firearms were common among young suicide victims (18–29 years) and in urban areas. Prevention work needs to emphasize strategies to reach firearm owners at risk of suicide. Local health and healthcare-related factors, as well as geographic and demographic factors, should be considered in tailoring such strategies.

This study examined all unintentional firearm fatalities while hunting that occurred in Sweden between 1983 through 2008. The circumstances as well as the impact of the hunter's exam on fatality frequency were analysed. During these 26 years, there were 48 such fatalities, representing 53% of all (n = 90) unintentional firearm deaths during the same period. The average annual number of fatalities decreased over the last few decades. Very restrictive firearm legislation in Sweden combined with the introduction of a mandatory hunter's exam since 1985 accounted, at least partly, for this finding. Moose hunting accounted for 46% of the fatalities and small game hunting for the remaining cases. The mean age of the victims was 50 years and 96% of them were males; all shooters were males. During moose hunting, most of the victims were mistaken for game, whereas in small game hunting most of the fatalities were related to falls and improper handling of the weapon. Human error was thus the main cause of these fatalities.

Although child mortality is decreasing in Sweden, an increase in suicide rates has been previously observed among children and adolescents collectively. To increase knowledge about trends, demographics, and means in child suicides, data including all child (< 18 years) suicides in Sweden in 2000 through 2018 were retrieved from the Swedish National Board of Forensic Medicine. In all, a total of 416 child suicides were found in a 19-year period, accounting for an annual suicide rate of 1.1/100,000 child population. The number of suicides increased with 2.2% by each successive year during the study period (p < 0.001). The mean age in both sexes was 16 years; boys accounted for 55% and girls for 45% of all study cases. The majority of the children who died by suicide (96%) were teenagers (13–17 years old) and suicides in children younger than 10 years were uncommon. Suicide methods were 59% hanging, 20% lying/jumping in front of a moving object, 8% jumping from a height, 7% firearm injury, 4% poisoning, and 2% other methods. Sex differences were significant (p < 0.001) only for firearms being preferably used by boys. The vast majority of firearms used were licensed long-barreled weapons. Conclusion: The number of child suicides in Sweden is relatively low but increasing. Most of the children used a violent and highly lethal method. Prevention of premature mortality is an urgent concern with an emphasis on resolutely reducing the availability of suicide means.

What is Known:

• Suicide is a significant cause of death globally among children, bringing tragic consequences for young individuals, their family, and the entire society.

• Suicide rates and distribution of suicide methods in children differ between countries and settings, but studies of time trends are scarce.

What is New:

• Increasing number of minors’ suicides and the predominance of violent methods emphasize the importance of prevention strategies tailored for a child population.

• Even in a setting of very restrictive firearm laws, firearm suicides in children must not be overlooked.

Since any firearm injury is potentially lethal, it is of great interest to prevent firearm incidents. This study investigated such incidents during hunting and Swedish hunters' safety behaviour. A 48-item questionnaire was posted to a random sample of 1000 members of the Swedish Association for Hunting and Wildlife Management. The questions considered demographics, hunting experience/hunting habits/safety behaviour/attitudes and experience of careless weapon handling, hunters' weapons and safety behaviour relating to weapons, health status, firearm incidents and their preventability, and personal comments on the questionnaire. The response rate was almost 50%. The mean age of the responders was 54 years; 5% were females. Almost none (1%) reported hunting under the influence of alcohol. Young age and male sex were positively associated with risk behaviour, although the presence of multiple risk behaviours in the same responder was not common. A very high degree of compliance with Swedish laws regarding weapon storage was reported. One-quarter of the responders had witnessed a firearm incident caused by another hunter, which in most situations did not result in human injury or death. An unsafetied weapon was the most common reported "cause" of these incidents. Experience of a firearm incident was not uncommon and the majority of the responders considered the incident in question to be preventable. This study provides a picture of the possible risk behaviour among hunters and the results suggest that future prevention work should target safer weapon handling.

Background: Sweden’s firearm legislation obligates physicians to report patients that are deemed unsuitable to possess a firearm. This study aimed to explore the involvement of firearm use in firearm fatalities and to evaluate physician reporting concerning cases of firearm deaths.

Methods: Fatal firearm suicides and homicides in Sweden were studied for the years 2012–2013, accidental deaths and undetermined manner of deaths for the period 1987–2013. Police reports and autopsy protocols were collected from the National Board of Forensic Medicine, healthcare data in 1 year before the fatality from the National Board of Health, and information about physician reports and firearm licences from the Swedish Police.

Results: A total of 291 firearm deaths (213 suicides, 52 accidental deaths, 23 solved homicides and 3 cases with undetermined manner of death) were identified. Firearm suicides were positively correlated with the number of licensed firearm owners. Legal firearm use predominated in firearm suicides and accidental deaths, illegal in homicides. No suicide victim or shooter in an accidental death was previously reported by a physician to the police according to the firearm law. The majority of the shooters in accidental deaths and suicides had no registered health care visits. Less than half (42%) of all suicide victims had a previous health care contact due to mental health problems. Conclusions: Not one single suicide victim nor any shooter in accidental deaths in the present study had been reported according to the firearm law, bringing the evidence of a suboptimal framework.

We examined the association between unintentional nonhunting firearm deaths and changes in firearm legislation in Sweden. There were 43 fatalities during the study time frame 1983-2012, representing 46% of all unintentional firearm deaths during the same period. The victims were predominantly young males (mean age 25 years). Slightly more than half of the deaths were caused by another person and were inflicted at close range. The main cause of the incidents was human error. The majority of the involved firearms were legal; however, most victims killed with illegal firearms were under the influence of alcohol and/or drugs at the time. The death rate decreased significantly following the introduction of the hunter's examination in 1985. Education and training associated with the hunter's examination was at least partially responsible for the decline in fatalities after 1985. Future prevention should target the availability of illegal firearms.