An autopsy found that financier Jeffrey Epstein suffered multiple breaks in his neck bones, according to two people familiar with the findings, deepening the mystery about the circumstances around his death.

Among the bones broken in Epstein’s neck was the hyoid bone, which in men is near the Adam’s apple. Such breaks can occur in those who hang themselves, particularly if they are older, according to forensics experts and studies on the subject. But they are more common in victims of homicide by strangulation, the experts said.

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The revelation of Epstein’s neck injuries follows reports that officers at the Metropolitan Correctional Center broke protocol and failed to properly monitor him.

Corrections officers had not checked on Epstein for “several” hours before he was found hanging in his cell, a person familiar with the matter said, one of a series of missteps in the hours leading up to his death.

Veteran prosecutors and law enforcement officials were shocked that one of the most high-profile inmates in the country wasn’t more carefully watched. Barr said over the weekend he was “appalled” at serious “irregularities” in jail protocol, and he later transferred the warden to another facility.

UPDATE: A reader comments:

I am an internist.

I am sure that many medical students all across the country will testify to the fact that this very issue is a very common teaching point in Gross Anatomy in the very first semester of medical school.

It is exceedingly important to recognize that there are two different kinds of “hanging” and the injuries left behind are completely different.

The Old West “drop the floor out” 15 foot above the ground is the kind of hanging that comes to most people’s minds. The person in this case is instantly pithed. Their spinal cord is instantly severed between the fracture of their C1 C2 or C3 vertebra. The hyoid is also almost always snapped as well. Death would be rather instant. The diaphragm would be denervated and they would quit breathing instantly.

The victim has to be weighed ahead of time – and the number of knots the hangman places in the rope is based on their weight. The tightness of the rope guarantees the preferred outcome. Too few knots and the neck will not break – but rather they will just be smothered – a miserable way to die. Too many knots – and the fall from the drop will decapitate them. Just the right number of knots – and the person will have their neck broken as above – and the death will be clean and quick. Their weight is critical to the process. The preparation of the rope is quite a skill – and is not easily done by amateurs.

As you can imagine – this type of “hanging” is impossible to accomplish in a jail cell.

The other method is to tie the person up, place the noose over a tree – and kick the bucket out from under them – or have the horse gallop and leave them hanging. There is no meaningful fall. This will break ZERO bones. The victim will be left tied up and hanging – but their brain will slowly be starved of oxygen as the noose is tightened around the carotid arteries. They will slowly suffocate – and often there are seizures, involuntary movements – vomiting, urination and defecation for the next 10-15 minutes as the person died. A miserable way to die.

The most important thing to note about these two is that the second way described above would be the route taken by someone in a jail cell with sheets or clothes or whatever they had. I have worked in an inner city hospital system for decades – and the number of people who successfully suicide this way is vanishingly small unless they also dope themselves up with drugs. Why? The misery is so intense they always stop no matter how much they want to die. Also – in my entire career – I have never seen a single case like this where there were broken bones – including the hyoid.

Today – I had occasion to speak to an old friend of mine from residency who is the medical examiner in a major US city – and asked him had he ever seen a prison hanging suicide attempt with broken bones. His experience is 30 years. The answer is HELL NO.

The broken hyoid then is indeed the issue. A strangulation with hands or other instruments such as belts or ropes will actually often break the hyoid. (This is because the victim almost always will have their head bent back by the force – and the hyoid will be exposed right around the middle). In a jail cell by ones self, there is very little else that would break the hyoid. I have seen it damaged in car wrecks, sports injuries and skiing accidents – but not someone sitting in a jail cell. The bone itself is very thin and fragile. However, it is a very very difficult bone to bother in a normal human – it is mostly completely protected by the mandible (jaw bone) – one of the hardest and most solid bones in the human body.

What I am saying is this is very very fishy – this does not make sense – and I would never accept this report on a patient of mine.