Strangulation Research in State of North Carolina v. Mark Bradley Carver

Warning! This page contains graphic descriptions and death scene photos.

A suicide reenactment video is shown above. If you or someone you know is at risk for suicide, please call 1-800-273-8255 in the USA or visit Suicide Prevention Lifeline. The video transcript is as follows:

This is a suicide reenactment. Tried to drive her car underwater. Crashed on the bank. Got out, tried to drown herself. Couldn't without a way to keep herself down. Used items from her car and clothing to strangle herself. This theory of the 2008 death of Ira Yarmolenko is consistent with evidence at the scene and forensic science research. FREEMARKCARVER.COM.


On May 5, 2008, 20-year-old Ira Yarmolenko was found dead on the bank of the Catawba River in Mount Holly, North Carolina. Pathologist Chris Nguyen, M.D., performed the autopsy and listed her death as a homicide due to asphyxia secondary to ligature strangulation, stating that she could not have tied the ligatures as they were found. When Dr. Nguyen testified during Mark Carver's trial on March 17, 2011 (pages 310 - 327), he confused the order of the ligatures and made several other assumptions in his evaluation compared to available research on suicidal strangulation that should have been brought into question. Possibly because Dr. Nguyen listed the death as a homicide on his autopsy report, other physical and circumstantial evidence that pointed toward suicide was disregarded by investigators, legal counsel for the prosecution and some of the legal counsel for the defense due to the misconception that suicidal strangulation would have been impossible. This report which includes references to forensic science research articles on suicidal strangulation shows that suicide was indeed possible in Yarmolenko's death and that case evidence supports this. This report is divided into three parts, questions about Dr. Nguyen's autopsy evaluation and his subsequent trial testimony, supporting suicidal strangulation research and observations from filming the suicide reenactment.

Part 1: Autopsy and Subsequent Trial Testimony Questions

Autopsy Question #1: Order of Ligatures

Order of ligatures in Yarmolenko death places ribbon first.

Compared to photos from the scene, it is possible that Dr. Nguyen may have switched the order of the ligatures during his testimony for Carver's trial, although it is also possible the ligatures may have shifted during transport of the body. He did not visit the scene of death, although he did say he had viewed photos of the positioning of the legs and hands.

There were three ligatures present upon my examination. The first ligature that was tied was a length of black cord which I feel was consistent with the drawstring from the victim’s hooded sweatshirt and that ligature was wrapped twice around the decedent’s neck very tightly (page 314).

Defense attorney Brent Ratchford cross-examined Dr. Nguyen about the order of the ligatures, as follows:

A. . . . The second ligature was most likely that blue ribbon just because it was lying partially on top of that corded cord from her sweatshirt, and then exterior to both of those was the bungee cord which was wrapped two times around her neck and clamped on the back. So in my best opinion it was the cord from the sweatshirt, then the blue ribbon, then the bungee cord.


Q. And that is merely from the way you found it during the autopsy?

A. Correct.

Q. You did not visit the scene?

A. No, I did not.

Based on the above photo and others taken at the scene, it would appear that the ribbon - not the drawstring - was the first ligature. Mount Holly Police Investigator William Terry who had been at the scene of Yarmolenko's death and who testified earlier during trial listed the order of the ligatures citing the ribbon first (March 16, 2011, page 128). This is important because the ribbon also appeared to be loose on the neck in scene photos, allowing Yarmolenko more time to have possibly tied the remaining two ligatures. The ribbon is standing out away from the neck with hair falling beneath it in the scene photo below.

Ribbon in Yarmolenko death was loose on the neck in scene photos.

Autopsy Question #2: Manner of Death

Dr. Nguyen stated the cause of Yarmolenko's death as "asphyxia secondary to ligature strangulation," and during his trial testimony he described the effects of restriction of blood flow, a phenomenon which in suicidal strangulation research literature is different from blockage of the airway (also known as mechanical asphyxia). Restriction of blood flow can cause death at lower pressures than that at which mechanical asphyxia occurs. Dr. Nguyen never provided measurements of the pressure of ligatures. Complete blockage of the airway in mechanical asphyxia requires 7 pounds while blockage of blood flow requires 4.4 pounds according to some studies. The vagal reflex can stop the heart at neck pressures below 4.4 pounds. In other words, Yarmolenko could have died from restriction of blood flow even while still having an unobstructed or partially obstructed airway, commonly seen in suicidal strangulation (see research in Part 2). Dr. Nguyen stated the following during trial related to blood flow as recorded in the trial transcript:

In my opinion ligatures that are tied that tightly around the neck would cause cessation of blood flow to the head and more importantly the brain and would cause a lack of consciousness, passing out basically, relatively quickly (trial transcript, page 315). . . . What I saw in the pictures of her eyes were actually things that I saw during the actual autopsy itself as well, which was the presence of multiple small pinpoint hemorrhages on both eyes involving the whites of her eyes, the sclera, and also the conjunctiva of her eyes, and there were small tiny red hemorrhages. Some of them were individual. Some of them were multiple and coalesced together (trial transcript page 319). . . . These are caused by essentially rupture of small capillaries which are present in your eyes. Whenever ligatures are applied or pressure is applied to your neck, it closes off the vascular or the blood flow to your head, and that blood cannot get out of your head and pressure builds up in your head and so small capillaries tend to burst and when they burst they drop a small drop of blood into the soft tissues and that is what you are seeing there, and they are called petechia (trial transcript page 320). . . . I believe the victim died secondary to asphyxia which was caused by ligature strangulation (trial transcript page 322).

Suicidal strangulation research places more emphasis on restriction of return blood flow from the head as a cause of death than of restriction of blood flow into the head. Logically, if blood flow had been restricted in flowing to the head as Dr. Nguyen claimed, then there would be no new blood to build up in the head causing the hemorrhaging effects he observed in the eyes. "Asphyxia" as a definition has been considered in need of more standardized measures for classification (see this 2010 reference that recommends classifying asphyxia into four categories with subcategories).

Yarmolenko's head swelled from the first police photos taken at the scene to the last photos taken before the body was removed, so it is possible that Dr. Nguyen's description of all three ligatures as "tight" throughout his trial testimony could be a result of this swelling that occurred after Yarmolenko's death.

Autopsy Question #3: Time Required for Death by Suicidal Strangulation

Yarmolenko's foot underneath brush at scene.

Ira Yarmolenko's feet in brush at scene.

Dr. Nguyen mentioned suicide during Carver's trial in the context of how he determined whether Yarmolenko's death was a suicide or a homicide. His explanation shows that he at least considered the possibility of suicide based on the condition of the body. He stated during trial:

What struck me the most besides the confirmation that the ligatures were there as well was just the overall positioning of the victim’s body. As you can see in this picture, her legs are underneath the brush. This leg is also partially covered by brush. She appears to be grasping also some of those grass blades or branches and just the abnormal way that her legs are laying. Her left leg is sort of bent at an angle that way. For this to have been anything but a homicide, i.e., this was a suicide, this victim would have to tie three ligatures around her neck tightly and before death get into this position while that’s going on and her legs underneath the brush given that position and I just feel like that was not consistent with what we are seeing. . . . Yes, and another thing that this illustrates a little bit better also is the presence of particular matter, soil and grass on her skirt as well. So that’s another thing that would have had to happen. If this was a suicide she would have had to do all this stuff by herself. It is just not consistent with that theory (trial transcript pages 323-324).

Yarmolenko's clothes were wet, and during the suicide reenactment described in Part 3 of this report, grass and dirt naturally stuck to a wet hoodie and skirt simply by lying down on the ground. Some dirt particles also remained on the clothing from having been in a river beforehand.

Contrary to what Dr. Nguyen testified as far his observing the ribbon to be tight, possibly due to progressive swelling as mentioned earlier, the first ligature, the ribbon, appeared to be loose in some of the photos taken at the scene. This means that the remaining two ligatures were more likely the time-critical ones. Due to swelling of the head, they may have appeared tighter at the time of the autopsy than they were at the time of death. "Congestion of the head" is a phrase repeated among several research articles about findings in suicidal strangulation.

Documented suicidal strangulations show that multiple ligatures with multiple knots are "not uncommon." Use of personal items as ligatures is a hallmark of suicidal strangulation, as seen in Yarmolenko's case. These and other possible findings in suicidal strangulation are cited in Part 2 of this report.

Given that it would be unlikely for attackers to take time to entangle Yarmolenko's legs in brush after she became unconscious and that Yarmolenko's hand was grasping brush rooted to the ground where she lay - indicating she was still alive when she came to her final resting spot - it seems logical that she could have pushed her own legs into the brush. It is possible that Yarmolenko may have thrashed around on the ground prior to becoming unconscious or that her feet may have slipped into the brush while trying to walk back down into the river, as actually happened to the actress during one take of the reenactment.

Autopsy Question #4: Lack of Supporting Injuries for Defining the Death as a Homicide

When someone has died by ligature strangulation, the extent of other injuries is helpful when determining whether the death was caused by homicide or suicide. In suicide, the ligatures must of course be intact when found and the hands unrestrained. The hyoid bone in the neck is rarely broken in suicide. Hemmorhaghing in the neck and damage to structures of the neck are common in homicidal strangulation. Yarmolenko's hyoid bone was intact, and her body showed few other injuries. Yarmolenko did have a rectangular-shaped patch of redness on her right thigh which could have been caused by impact with the steering wheel or other part of the car during the crash. Injuries other than to the neck area in suicide are sometimes related to previous suicide attempts, which in Yarmolenko's case could have been the car crash and drowning attempts.

Bruising on Ira Yarmolenko's leg.

Ira Yarmolenko's hand grasping brush.

Small scrape on Ira Yarmolenko's hand.

Defense attorney Brent Ratchford cross-examined Dr. Nguyen during Carver's trial, bringing out the lack of supporting injuries which would normally be expected for a homicide and the possibility that brush in the area could have caused the small scrape on Yarmolenko's finger.

Q. And when you examined Ms. Yarmolenko’s neck were there any marks to her necks other than the ligature marks such as a grasping from claw marks or fingernail marks or anything like that?


A. I did not see anything that I could definitely say was that, no.

Q. You saw no defensive wounds or anything like that on Ms. Yarmolenko, either, did you?

A. It would depend on your definition of defensive wounds.

Q. Any broken fingernails or cuts or anything like that?

A. I did not see any broken fingernails. There was a small laceration on the index finger of her right hand.

Q. The area that you - you made a notation that she was grasping in the brush area?

A. Yes.

Dr. Nguyen stated the scrape was on the right index finger, but the only publicly available photos from the scene show a scrape on the left index finger.

Part 2: Supporting Suicidal Strangulation Research

Suicidal Strangulation with Multiple Knots and Multiple Ligatures

“According to many observations, neither the use of more than one ligature nor repeated knotting is strongly indicative of a homicidal action. The use of more than one ligature has been repeatedly reported in suicides as well as multiple turns up to 20. . . . Half knots as well as double knots have been described in the literature and observed in our material in both [suicidal and homicidal] groups . . . In suicides, the majority of reported positions of knots was in the frontal or lateral neck region, but knots in the back of the neck have also been observed as well as both positions in the same case. More than one knot in suicides is not unusual (. . . with up to three or four knots having been reported . . . ).” [1]

“This paper reports the case of a 20-year-old university student found dead . . . . The cause of death was strangulation. On the basis of the police investigation and the results of the autopsy I performed, the case was unquestionably found to be suicide, even though two double and two single knots had been found in the noose around the neck. . . . All the knots, single and double, were firmly tied. Unwinding them, one could not have said that any of them had been in any looser than the others. . . . Every future case of strangulation with a double knot of the noose will certainly present the same dilemma: was it suicide or murder? The logical thing in such cases is to think of murder first. But, if a number of relevant facts point to suicide, and there are no facts pointing to murder, we must allow the possibility of suicide.” [2]

“In the majority of strangulation cases, the ligature is crossed over itself after passing a full circle around the neck—and several turns may be found around, secured with one or more knots. These multiple turns are not uncommon in suicide, where two, three, or even more circles are found around often with complex knots.” [3]

“It is such a case of self-garrotting that is considered in this report. . . . Looped around the neck and tied in the back were two maroon bow ties . . . .” [4] “The tying of a double knot in cases of suicide has been explained by Glaister (1962) and Zecevic (1982) and the winding of a flex several times around the neck is described by Vanezis (1989).” [5]

Suicidal Strangulation Mistaken for Homicide

“Suicide by self-strangulation is uncommon, but we have only to glance through the forensic literature to realize that many cases of ‘atypical’ strangulation have been described. Despite this, many authors and criminal investigators continue to believe that self-strangulation is not possible and that strangulation therefore must represent homicide. . . . There are a great many different methods for committing suicide, but few are likely to be confused with homicide. Self-strangulation is one of those that—at least at first sight—may easily be mistaken for homicide because many investigators and forensic pathologists believe that it is impossible to carry out self-strangulation as a means of suicide. This is due to the misconception that strong pressure is needed on the neck to occlude the airways and the arterial vessels of the neck. Polson has brilliantly demonstrated that a force of only 3.2 kg [7 pounds] is necessary to occlude the airways, whereas a force of 2 kg [4.4 pounds] is enough to occlude the venous system. Moreover, to stimulate the vagal reflex, even minimal pressure may suffice. . . . This [vagal reflex] response to compression of the neck brought about rapid death from cardiac arrest caused by vagal inhibition, well before any signs of stasis or increased blood pressure could develop.” [6]

“In judicial and police circles—sometimes even in circles of medical professionals—it is still often thought that suicidal strangulation by ligature is impossible. Reviewing the forensic literature we could find more than 200 cases that have been published earlier. We report another 4 cases of suicidal strangulation. . . . Primary investigation of the corpse in original position by a forensic scientist is of high importance.” [7]

“Self-strangulation by ligature is an uncommon event, and may give rise to difficulty in diagnosis. If a victim is found with the ligature still present, the evaluation of the mode of death (suicide—homicide?) can be an extremely complex objective.” [1]

External Injuries Other Than to the Neck Region

"Only 20% of the homicidal victims had no injuries except those caused directly by strangulation, whereas this was seen in 80% of suicides. . . . The additional external injuries found in our suicides were either self-inflicted (incisions on the wrists) or were insignificant in their intensity and could easily be interpreted as accidental.” [1]

Personal Items Used as Suicidal Ligatures

“In the current report, death in all 3 cases was due to pressure of both the airway and venous system. . . . There were not any findings which were suggestive of homicide in the death scene investigation of any of our 3 cases. There were no defensive wounds on any of our corpses. A suicide note was found in the first case. The actions in all of our cases were carried out with common, personal goods (i.e., a belt, pantyhose, and a scarf). It was concluded, based on all of the above stated findings, that the cause of death in each of the 3 presented cases was suicide.” [8]

“Self-strangulation by a ligature fashioned from the subjects’ clothes was the mechanism of suicide in both cases.” [9]

Elastic Band in Suicidal Strangulation

“The rarity with which elastic bands are used for suicidal strangulation is probably explainable by several factors. Most people, including misinformed medical professionals, believe that great pressure, at least equal to body weight, must be applied to the neck in order to end one’s life. Consequently, it may be a common misconception that apparently flimsy elastic bands are incapable of transmitting lethal force. In fact, great pressure is not needed to stop effective cerebral blood supply. . . . Whereas sudden interruption of arterial blood supply to the brain may cause rapid death, the significance of obstructed venous return is much less obvious.” [10]

“A rare case of suicidal strangulation with four looped rubber bands is reported.” [11]

Gradually Applied Tension in Suicidal Strangulation

“Normally, self-ligature strangulation is prevented as the individual becomes unconscious as the venous circulation is obstructed, leading to relaxation of the ligature tension. In this case, the successive layers of twine [35 circumferences] provided gradually applied tension . . . . Usually the blood supply (venous) is occluded prior to actual respiratory suffocation occurring, rendering the victim comatose prior to death. . . . Actual respiratory suffocation probably does not occur in most ligature strangulations.” [12]

Additional Suicidal Strangulation Literature

Three additional articles are included as references to supplement the previous findings about suicidal strangulation. [13][14][15] This report was originally prepared in January 2013, and by August 2016, three new articles about suicidal strangulation had been published which are similar to the preceding articles in their remarkable clarity in illuminating evidence in the Yarmolenko case. [16][17][18]

References for Part 2

Due to copyright restrictions, the full texts of the referenced articles may not be published online, but interested individuals may access them electronically at most medical research libraries or may contact us for assistance in obtaining the full texts.

  1. Maxeiner H, Bockholdt B. Homicidal and suicidal ligature strangulation—a comparison of the post-mortem findings. Forensic Sci Int. 2003 Oct 14;137(1):60-6. PubMed PMID: 14550616.
  2. Zecević D. Suicidal strangulation with a double-knotted noose. J Forensic Sci. 1982 Oct;27(4):963-7. PubMed PMID: 7175479.
  3. Demirci S, Dogan KH, Erkol Z, Gunaydin G. Ligature strangulation deaths in the province of Konya (Turkey). J Forensic Leg Med. 2009 Jul;16(5):248-52. doi:10.1016/j.jflm.2008.12.013. Epub 2009 Jan 14. PubMed PMID: 19481705.
  4. Rupp JC. Suicidal garrotting and manual self-strangulation. J Forensic Sci. 1970 Jan;15(1):71-7. PubMed PMID: 5419863.
  5. Claydon SM. Suicidal strangulation by ligature: three case reports. Med Sci Law. 1990 Jul;30(3):221-4. PubMed PMID: 2398799.
  6. Di Nunno N, Costantinides F, Conticchio G, Mangiatordi S, Vimercati L, Di Nunno C. Self-strangulation: an uncommon but not unprecedented suicide method. Am J Forensic Med Pathol. 2002 Sep;23(3):260-3. PubMed PMID: 12198353.
  7. Rabl W, Markwalder C, Sigrist T. ["Self-asphyxia"--a forensic medicine-criminal challenge]. Arch Kriminol. 1992 Jan-Feb;189(1-2):1-8. German. PubMed PMID: 1580728.
  8. Demirci S, Dogan KH, Erkol Z, Gunaydin G. Suicide by ligature strangulation: three case reports. Am J Forensic Med Pathol. 2009 Dec;30(4):369-72. doi:10.1097/PAF.0b013e318187e06b. PubMed PMID: 19901818.
  9. Kennedy NM, Whittington RM, White AC. Suicide by self-strangulation whilst under observation. Med Sci Law. 1995 Apr;35(2):174-7. PubMed PMID: 7776869.
  10. Kogan Y, Bloom T. Suicidal ligature strangulation with an elastic band. Am J Forensic Med Pathol. 1990 Dec;11(4):329-30. PubMed PMID: 2275472.
  11. Lin Z, Kondo T, Sato Y, Ohtsuji M, Takayasu T, Ohshima T. An autopsy case of suicidal strangulation with four looped rubber bands. Nihon Hoigaku Zasshi. 1997 Jun;51(3):231-4. PubMed PMID: 9301230.
  12. Frazer M, Rosenberg S. A case of suicidal ligature strangulation. Am J Forensic Med Pathol. 1983 Dec;4(4):351-4. PubMed PMID: 6666763.
  13. Gaur JR, Verma RK, Thakur GC. Suicidal strangulation. Med Sci Law. 1992 Jan;32(1):55-6. PubMed PMID: 1740982.
  14. Scott KWM. A case of homicide followed by suicidal strangulation. Med Sci Law. 1992 Jan;32(1):47-50. PubMed PMID: [None available].
  15. Koops E., Brinkmann B. [Suicidal strangulation by ligature (author's transl)]. Z Rechtsmed. 1982;88(3):221-31. German. PubMed PMID: 7102116.
  16. Tzimas Il, Bajanowski T, Pollak S, Trübner K, Thierauf A. Suicidal ligature strangulation using gymnastics bands. Int J Legal Med. 2014 Mar;128(2):313-6. PubMed PMID: 24429766
  17. Zorro AR. Suicidal strangulation by double ligature: A case report. Med Sci Law. 2014;54(2):110-112. PubMed PMID: 24052004.
  18. Pramanik Pl. An Unusual Method of Suicidal Ligature Strangulation. J Forensic Sci. 2016 Jan;61(1):274-6. PubMed PMID: 26211537

Part 3: Suicide Reenactment Observations

Ira Yarmolenko's possible injury to thigh during car crash.

Path down embankment traveled by Ira Yarmolenko.

Mud was spun up underneath Ira Yarmolenko's car tires at the scene of her death.

While filming a reenactment of the suicide theory of Yarmolenko’s death, several observations were noted. The steering wheel could have created a sharp impact during the crash, resulting in bruising on the top of Yarmolenko’s lower right thigh. Broken vegetation shows that the car appears to have been steered down the rough embankment, landing in the precise center of the clearing. Dirt spun underneath the tires indicates that the car either remained in motion after the crash or was stopped and re-started after the crash. The suicide theory proposes that Yarmolenko first attempted to drive her car into the river and then resorted to other suicide methods after the crash.

Self-drowning without an attached weight is nearly impossible because of natural reflexes to come up for air. The suicide theory proposes that Yarmolenko’s self-drowning attempt failed. A duplication of Yarmolenko’s possible backward submersion revealed that the legs tend to float upward and the head is instinctively held up to prevent water from painfully entering the nose. When the attempt was repeated in a sandy riverbed, little matter from the bottom of the river stayed on the clothing because the water washed most of it away upon exit. Later in the reenactment, wet clothing mixed with dirt on the ground when lying down after the final ligature was applied, and this is when most of the mud on the clothing was created.

No footprints were reported as found going into or out of the water at the scene of Yarmolenko’s death. In the reenactment, it was possible to step down into the river upon entry with dry clothing and shoes but then necessary to crawl out due to the angle of the riverbank, leaving no footprints at the river’s edge after submersion.

Scrape could have come from Ira Yarmolenko's cutting a ribbon with car keys.

The scrape on Yarmolenko’s index finger could have occurred as she cut ribbon with her car keys, but the scrape may have also come from the car crash, tree limbs or other groundcover at the scene. Multiple light scratches covered both forearms of the actress following the reenactment, a result of brushing against vegetation while in the water and on the ground.

The ribbon was slick and difficult to tie tightly, making it the weakest of the three ligatures in the reenactment. In the reenactment, the hoodie drawstring created extreme discomfort, with enough pressure to cause a gag reflex, a panic reflex and pressure building up in the head with intense pressure behind the eyes. In the reenactment, the bungee cord exerted less pressure than the hoodie drawstring. However, the bungee cord added enough extra pressure to cause the actress to be unable to talk and to momentarily lose vision with the eyes blacking out. The bungee cord was immediately released when the loss of vision began. The actress’s neck was sore for two days following the reenactment. In other words, this reenactment could have been dangerous, and care was taken to release the ligatures as soon as possible and have assistants standing nearby for safety.

Notice in original case photos the angles at which the bungee cord hooks are found. A right-handed person will naturally use the right hand to operate the hooking motion and the left hand to hold the other hook flat against the neck. Yarmolenko was right-handed.