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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 av skottskador representerar en viktig folkhälsofrämjande insats som kan rädda människoliv. En av de största utmaningarna är skottskadornas höga dödlighet. Självmord utgör den största andelen av dödsfall med skjutvapen i Sverige, följt av mord/dråp och dödsolyckor. Studier av dödliga skottskador är emellertid fåtaliga, både i Europa och i Sverige. Dödliga skjutvapenolyckor har tidigare undersökts i Sverige på 1980-talet. Det visade sig då bland annat att dödsolyckor relaterade till jakt var något vanligare än dödsolyckor utan samband med jakt.

Syftet med denna avhandling var att undersöka dödsfall med skjutvapen i Sverige med särskilt fokus på dödsolyckor och deras tidsmässiga utveckling. Undersökningen omfattar preventionsaspekter relevanta för dödsskjutningar, oavsett dödssätt. Uppgifter om dödsfallen inhämtades huvudsakligen från Rättsmedicinalverkets databas, men även från Patientregistret, Läkemedelsregistret och Vapenregistret. Genom en enkät till svenska jägare undersöktes även icke dödliga skjutvapenincidenter vid jakt.

Jakt är en traditionell fritidsaktivitet i Sverige, ofta av familjekaraktär. Alla jägare ska sedan 1985 ha genomgått jägarexamen innan jaktvapenlicens utfärdas av Polismyndigheten. Detta år blev jägarexamen obligatorisk och utbildningen ger en bred kunskap om bland annat jaktformer, viltarter, lagstiftning, skytte och tillvaratagande av bytet. Dödsolyckor med skjutvapen under jakt har varit ovanliga i Sverige men har inte undersökts under senare decennier.

Avhandlingens första delstudie handlar om dödliga vådaskjutningar i samband med jakt (N = 48) och under åren 1983-2008. De avlidnas medelålder var 50 år och 96% var män. Den mänskliga faktorn, som var den viktigaste orsaken till dessa olyckor, innebar oftast en felaktig bedömning av målet (människa förväxlades med djur), felaktig vapenhantering, eller fall med laddat och eventuellt osäkrat vapen. Incidensen av dödsolyckor har sjunkit i Sverige sedan 70-talet. Införande av obligatorisk jägarexamen har bidragit till en signifikant incidensminskning efter 1985 (1985-2008), jämfört med perioden dessförinnan (1970-1984).

Jägarnas jaktvanor, attityd kring säkerhet under jakten och erfarenhet av skjutvapenrelaterade incidenter undersöktes i den andra delstudien. En enkät skickades till 1,000 jägare och svarsfrekvensen var kring 50%. Medelåldern för dem som svarade var 54 år, och 5% var kvinnor. Omkring 1/4 del hade bevittnat en incident med skjutvapen som orsakats av en annan jägare. Jägarna föreslog ”den mänskliga faktorn” som orsak till dessa incidenter. Rapporterade incidenter ledde sällan till att en människa blev skadad eller dödad. Endast få jägare uppgav flera riskfaktorer eller flera riskbeteenden.

Dödliga skjutvapenolyckor utan samband med jakt och under åren 1983-2012 (N = 43) undersöktes i den tredje delstudien. Mer än hälften (56%) av dödsfallen orsakades av en annan person. Offren var främst unga män och medelåldern var 25 år. I 63% av fallen användes ett legalt vapen, men fynd av alkohol och narkotika i blodet var vanligare bland de offer där ett illegalt vapen använts. Den mänskliga faktorn var den huvudsakliga olycksorsaken. Risken att dödas i en skjutvapenolycka minskade signifikant efter införandet av jägarexamen 1985, jämfört med åren 1970-1984.

Den fjärde studien omfattade 52 dödsolyckor med skjutvapen (1987-2013), 3 fall av dödliga skottskador med oklart dödssätt (1987-2013), och, under åren 2012-2013, 213 självmord med skjutvapen och 23 lösta mord/dråp med skjutvapen. Antalet självmord korrelerade till antalet vapenägare i respektive län. Användning av ett legalt vapen dominerade bland självmord och dödsolyckor, medan ett illegalt vapen var vanligast bland lösta mord/dråp. Majoriteten av skyttarna i dödsolyckor och självmord hade inget registrerat besök i slutenvård eller den specialiserade öppenvården. 42 procent av alla självmordsoffer hade undet det sista året i livet kontakt med sjukvården pga psykiska problem. Inget självmordsoffer och ingen skytt i en dödsolycka hade rapporterats till polisen av läkare enligt vapenlagen.

Denna avhandling bekräftar att dödliga skjutvapenolyckor är sällsynta i Sverige. Obligatorisk jägarexamen bedöms ha bidragit till incidensminskningen efter 1985. För dödsolyckor är den mänskliga faktorn en viktig bakomliggande orsak som kan påverkas av framtida preventionsinsatser. Av alla dödliga skottskador tar dock självmord flest liv. Läkares anmälningsskyldighet enligt vapenlagen är emellertid inte välfungerande i dagsläget. En förändring krävs i denna del, liksom andra åtgärder för att minska antalet självmord. Illegala skjutvapen har varit inblandade i en betydande andel dödsfall, och dessa kan inte förebyggas genom läkares anmälningsskyldighet. Även detta fynd bör beaktas vid framtida preventionsinsatser.

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.