Homicidal and suicidal sharp force fatalities: Autopsy parameters in relation to the manner of death

Lethal injuries in single stabs to the trunk - A study on homicides and suicides in Sweden

INTRODUCTION

Homicides using knives or other sharp objects are the most common type of homicide in Europe, and the second most common type of homicide worldwide. In contrast, suicides using sharp objects are rarer, constituting only a few per cent of all suicides in western countries. We investigated single stab injuries to the trunk in both homicides and suicides to assess differences in extent of injuries and in medical care, which could be of value for trauma management, public health and forensic assessment.

METHODS

We identified all cases in Sweden between 2010 and 2021 that died of a single stab to the trunk, in either a homicide (n = 94) or a suicide (n = 45), and that were the subject of a forensic autopsy. We obtained data on demographics, hospital care and injured structures. To assess the severity of injuries, we applied AIS (Abbreviated Injury Score) and NISS (New Injury Severity Score). The inter-rater reliability of NISS between two raters was evaluated with intra-class correlation (ICC), with 95 % confidence intervals (CI). The data was analysed using Fisher's exact test, Mann-Whitney U test and logistic regression models.

RESULTS

The inter-rater reliability between the two NISS raters showed an ICC of 0.87 (95 % CI 0.68-0.95). We observed a larger variation of injuries in suicides, with a higher proportion of both unsurvivable (NISS 75) and minor injuries (NISS ≤ 8) (66.7 % and 8.9 % respectively) compared to in homicides (46.8 % and 0 % respectively). We observed a larger proportion of injuries to the heart in suicides (68.9% vs. 46.8 %, p = 0.018). In homicides, injuries involving vessels (52.1% vs. 13.3 %, p < 0.001) and hospital care (56.4 % vs. 8.9 %, p < 0.001) were significantly more common compared to suicides.

DISCUSSION AND CONCLUSION

Causation (self-inflicted or assaults) seems to be associated with characteristics of injury and the likelihood of receiving hospital care. These findings could potentially be valuable for trauma management and forensic assessment of manner of death, however, determining the mortality of the injuries would require a comparison group comprising injured survivors.

Atypical suicide by single incising cut to the throat without hesitation marks: Case report and review of the literature

Several studies have been performed to recognize the main features in homicide and suicide sharp wound-related death, revealing that a single cutting wound to the neck is an infrequent event in suicide cases, and several hesitation marks near the fatal injury are usually present. We report a case of an atypical self-inflicted cutthroat injury without tentative marks involving a 79-year-old female. The weapon used, a kitchen knife, was found at the crime scene. The wound had clean margins, and no other incisions were found. Scene circumstances, namely the absence of signs of a break-in, the victim found on the bed, the knife located near the body, the vital wound in an accessible site, and the absence of defense injuries, collectively support a likely suicide. A literature review was also performed to compare forensic data of the case presented with the other 6 cases reported regarding atypical suicide characterized by a single incising cut to the throat without hesitation marks. Given the few cases reported and the lack of gross descriptions and histopathological data available in the literature, additional knowledge of such a case may help forensic pathologists in the identification of suicidal events when a single neck injury is observed. In this frame, suicide by a unique single incising cut to the throat without hesitation marks near the lethal injury may be observed as an atypical presentation, and the crime scene investigation, together with additional background information of the deceased, aid in the identification of the manner of the death.

Singular stab wounds to the trunk: Is this suicidal or homicidal?

Differentiating homicidal or suicidal deaths in presence of a singular stab wound to the anterior or lateral trunk is still a challenge in forensic practice. There are numerous criteria in the literature and in current forensic textbooks to distinguish between self-inflicted injuries and homicide. The applicability of these criteria in single stab injuries was examined by elucidating 12 suicides and 33 homicides, each with a single stab injury to the anterior or lateral trunk and were largely confirmed. An instrumentality still stuck in the corpse was always associated with a suicide in the given cohort. In summary, the final evaluation should always be based on an interpretation of the post mortem findings together with the circumstances on site of discovery as well as the results of the police investigation.

Spatial relationships among offender, knife, and victim during slashing attacks: implications for crime scene reconstruction

BACKGROUND

The offender-victim spatial relationship is crucial in reconstructing a crime scene. The study aims to evaluate the spatial relationship of performing slashing attacks on a dummy using a Chinese kitchen knife, and thus to establish a scientific basis for crime scene reconstruction.

METHODS

Twenty-four participants (12 males and 12 females) slashed a dummy's neck or chest using a kitchen knife, and the kinematic data were obtained using a three-dimensional motion capture system. The spatial relationships among offender, knife, and victim during slashing attacks were analyzed.

RESULTS

Slashing distance and occupancy area are significantly influenced by gender (all P < 0.05), with males having higher values than females. Body parts significantly influence bevel angle, offender and victim azimuth angles, slashing distance, relative slashing distance, and occupancy area (all P < 0.01), with slashing the chest resulting in larger values than slashing the neck.

CONCLUSION

Gender and body position significantly influence the spatial relationships of slashing action. Our data indicate that males stand farther away and occupy a larger area during slashing attacks. When the chest is slashed, the wound orientation is more diagonal, the offender's standing position and slashing distance are farther, and the occupancy area is larger compared to the neck. The findings could help identify the spatial relationships among offender, knife, and victim, providing a scientific basis for criminal investigations and court trials.

The Noble Suicide: The Case of a Self-Contained Dagger in the Heart and a Literal Raw

According to WHO estimates, more than 700,000 people die each year due to suicide and suicides performed with a bladed weapon account for approximately 1.6%-3% of all suicides. It is statistically more common to find injuries to the heart, lungs, and thoracic vessels in homicides, whereas in suicides there is a higher frequency of vascular injuries to the extremities of the limbs. Also in suicides, the presence of "hesitation marks," related to the attempts the victim makes before having the courage to kill himself, can often be found. In the case presented by the authors, these parameters are subverted: There was only one injury and it was the fatal one, it was located on the chest and reached the heart. But it was suicide. The circumstantial data, the psychological explanation, and the previous similar suicide attempt left no doubt about it. The man decided to commit suicide because he could no longer find meaning in his life after losing hope for a career as a pianist, having been diagnosed with a degenerative disease in his hands. The man hated himself and his existence: The future appeared extremely negative and the only escape was self-suppression. This case report makes an essential contribution to the already existing Literature as it shows a suicide that occurred in an unusual manner.

Differentiating suicide from homicide in sharp-force fatalities with stab and/or incised wounds: A scoping review

The majority of sharp-force fatalities with stab and/or incised wounds are homicides. However, suicidal sharp-force fatalities with stab and/or incised wounds are also reported. Thus, distinguishing suicidal stab and/or incised wounds from homicidal stab and/or incised wounds is significant from the forensic perspective. This scoping review primarily summarizes the existing research findings on the differentiation of suicide from homicide in sharp-force fatalities with stab and/or incised wounds. The literature was systematically searched on February 28, 2023, using the PubMed database. A search string formed by a combination of keywords related to suicide, homicide, and stab and incised wounds yielded 23 records. After applying the eligibility criteria, six records/studies met the inclusion criteria and were included in the present scoping review. Results showed that the predictive strength of various parameters, either individually or collectively, in diagnosing the manner of sharp-force fatality as suicide or homicide is not always hundred percent accurate. Some of the important predictors of the homicidal manner of death in sharp-force fatalities include clothing damage, presence of defense injuries, presence of injuries caused by another type of violence other than sharp-force, vertically oriented chest stabs, and sharp-force injuries in the head and back anatomical sites. Some of the important predictors of the suicidal manner of death in sharp-force fatalities include the presence of tentative injuries, sharp-force injuries to the wrist, and the presence of a suicide note.

A Swedish nationwide forensic study of the manner of death in single stab injuries to the trunk

INTRODUCTION

Forensic pathologists are frequently confronted with questions about whether an injury is likely to have been inflicted by an assault or be self-inflicted. However, little is known of the epidemiological variables that might be applicable to differentiate between homicides and suicides in deaths caused by single stab injuries to the trunk.

METHOD

Using the Swedish forensic autopsy register, we identified 94 homicides and 45 suicides between 2010 and 2021 in which death followed a single stab injury to the trunk. We extracted characteristics from the cases and performed statistical analyses using the Mann-Whitney U test, Chi-square test and logistic regression model.

RESULTS

Victims of homicides were younger than suicide victims (median age 33 years vs. 52 years, p < 0.05), and males were in the majority in both groups (93% vs. 82%). In numerous homicide victims, stab wounds were placed in the back and in axillar regions, unlike in suicides victims in which the stabs were all placed on the medial part of the anterior trunk. Vertical entrance wounds in the skin combined with a medially running injury channel (n = 13) showed a positive predictive value of 100% (95% CI 75.3-100) for homicide, although the sensitivity was low. Homicides were conclusively associated with an outdoor death scene (OR 19.0, 95% CI 7.6-47.1), injury to thoracic bone/cartilage (OR 3.8, 95% CI 1.6-9.0), influence of alcohol (OR 7.1, 95% Cl 2.9-17.7) and illicit drugs (OR 4.3, 95% CI 1.5-11.9).

DISCUSSION AND CONCLUSION

The observed forensic characteristics of stab injuries could be used as a tool when assessing the manner of death in single stabs. Further research on variables associated with manner of death are needed and we suggest also including characteristics of surviving victims in such analyses.

Homicide or suicide? A probabilistic approach for the evaluation of the manner of death in sharp force fatalities

The role of forensic science can be defined as providing relevant opinions to assist investigators and courts of law in answering questions. The Likelihood Ratio (LR) provides a quantitative and logical approach to communicating the strength of expert evidence. We reviewed existing forensic literature on sharp force fatalities, focusing on studies reporting the manner of death and the frequency of some characteristics that are traditionally assessed. Four studies were included, resulting in a database of 173 suicides and 354 homicides. The LR of each of the characteristic under both hypotheses (suicide and homicide) was obtained. Subsequently, the LR was computed in six fatalities with known manner of death, three suicides and three homicides, by multiplying the corresponding LR of each individual characteristic. LR ranged from 115 to 140,250 in suicidal cases and from 9 to 2728 in homicidal cases. Compared to other fields of forensic science where LR is used extensively, the values obtained in our cases of sharp force fatalities is low. However, in forensic pathology there is evidence that is outside the expert's opinion, and it is for the trier of fact, such as the judge or jury, to draw conclusions. Nevertheless, the LR serves as a tool for interpreting and weighing evidence while maintaining the distinct roles of the trier of fact and the expert. To comprehensively apply the LR in the field of sharp force deaths, it will be necessary to standardize the methodology of investigation and data collection in descriptive studies.

Review of patterns in homicides by sharp force: one institution's experience

This paper presents a retrospective review of patterns found in cases of homicides by sharp force over a 13-year period at the Department of Forensic Pathology of the Ostrava University Hospital, Czech Republic. The review summarizes all frequently discussed aspects of such cases including the number and localization of injuries, the presence of defensive wounds, the type of the offending weapon, the cause of death, the place of death, victims' and perpetrators' profiles, their relationship, or toxicological findings. Furthermore, special attention was paid to the evaluation of any accompanying blunt force trauma that may be indicative of an escalation of the assault. The set of data was statistically analyzed. Even though most of the results of this review are consistent with available published studies, noteworthy differences have emerged in some aspects such as the sex and age of the victims, the relationship between the number of injuries suffered and the victims' sex, or the severity of alcohol intoxication in victims.

Correlation of soft tissue and skeletal injuries in cases of violent death: A retrospective study of autopsy cases for forensic anthropology

In forensic pathology, deaths due to mechanical injuries (blunt, sharp, and gunshot) require an autopsy in order to determine the cause and manner of death through a detailed examination of viscera, soft tissues, and the skeletal system. Sometimes, such as in cases of severe putrefaction, only the skeleton is observable. In such cases, the absence of bony defects does not mean that a trauma-related death should not be considered: yet, how often will a lethal mechanical death produce a defect in the skeletal system? The present study involved a retrospective review of autopsy reports to investigate the frequencies of soft tissue and related skeletal injuries in cases of violent deaths. A total of 200 autopsy reports for cases of four mechanisms of injury including sharp force trauma (n = 50), gunshot (n = 50), blunt force trauma (n = 50), and mechanical asphyxia (n = 50) were examined. Manner of death, localization of bone fractures, and correspondence between external injuries and bone fractures were reported. Frequencies of bone fractures and degree of correspondence with soft tissue injuries for each trauma group were evaluated. The result showed that lethal blunt trauma always caused bone fractures; 94.0% of violent deaths by gunshot involved bones; 48.0% of sharp force soft tissue injuries involved the bone tissue; and hyoid bone fractures were observed in 20.0% of cases of mechanical asphyxia.

The manner of death in a case with two stab wounds caused by two weapons: case report

Background

Stabbing is a relatively uncommon method of suicide. Typical suicide is usually associated with tentative wounds. Self-stabbing using two sharp weapons to produce two stab wounds without tentative marks is an uncommon incidence.

Case presentation

A 42-year-old Austronesian descent male with a history of family troubles was found dead by his friend inside a clothing store; two kitchen knives were present on both sides of the body. There were two stab wounds in the chest and the abdomen without any superficial hesitation cuts. At the crime scene, there were two blood pools.

Conclusion

The number of injuries with the absence of hesitation injuries raised suspicions of an atypical case of suicide that necessitated further forensic investigations. However, the circumstantial evidence and autopsy findings demonstrated that suicide was the cause of death.

Penetrating craniocerebral injury caused by bladed weapons: Three homicide cases

Penetrating craniocerebral injuries caused by a bladed weapon are rare events in western countries and often occur in the course of assault. We studied all homicide-related cases of cranial and brain injuries caused by bladed weapons that were seen at the Medicolegal Institute of Marseille over a 5-year period from 2014 to 2019. We found that such injuries are exceptional. The majority occur in the private sphere and are inflicted by men, as they require considerable force. They are rarely isolated but are accompanied by multiple cutting injuries of the thorax and abdomen. Such assaults leave imprints on the bone that can be analyzed using new anthropological techniques.

Perimortem Skeletal Sharp Force Trauma: Detection Reliability on CT Data, Demographics and Anatomical Patterns from a Forensic Dataset

Simple Summary

The increased use of computed tomography images in forensic anthropology is easily explained with a variety of benefits: among other reasons they are digitally stored, they can easily be shared and they are non-invasive. However, it is not clear how suitable these images are for forensic anthropologists to detect sharp force trauma. Therefore, we analyzed computed tomography images, by observing digital images of 41 forensic cases in different viewing modalities. In addition, we looked for anatomical injury patterns in the soft- and hard-tissues and any significant correlations between the manner of death (suicide or homicide) with different parameters. Our findings indicated a superiority of viewing the images in 2D, but not all bone lesions were detected. The manner of death was significantly correlated to some of the parameters, which could be extrapolated to future forensic anthropological cases. We promote the inclusion of imaging training into the anthropological curricula.

Abstract

The increasing importance of trauma analysis by means of postmortem computed tomography (PMCT) is insufficiently reflected in forensic curricula, nor are best practice manuals available. We attempt to detect sharp force bone lesions on PMCT of closed forensic cases with the aims of assessing errors and pointing out patterns in anatomical location and manner of death (MOD). We investigated 41 closed sharp force fatality cases, with available PMCT and forensic reports. Two observers with different radiological training assessed the lesions on PMCT scans (2D and 3D) for comparison with the reports. Between 3% (suicides) and 15.3% (homicides) of sharp force injuries caused visible bone lesions. While our observations were repeatable, each forensic investigation left a similar number of bone lesions undetected. Injury patterns differed between MOD, with thoracic bone lesions being most frequent overall. Soft tissue injury location varied between the MOD. Associations between MOD and age as well as number of injuries were significant. The detection of bone lesions on PMCT for untrained forensic specialists is challenging, curricula and pertinent manuals are desirable. With the low frequency of bone lesions compared to soft tissue injuries, we should be aware when analyzing decomposed bodies.

Atypical longitudinal self-inflicted incised wounds as a cause of death in an ecstasy user

A 32-year-old chronic drug abuser was found dead at the entrance to his home, covered in blood. Pools of blood, bloody footprints and bloodstains were found across the apartment. A double-edged razor was recovered from the scene. Autopsy revealed multiple incised wounds: two on the palmar aspect of both forearms (37 cm and 33 cm long, oriented longitudinally). The cuts extended into the subcutaneous adipose tissue, muscles and blood vessels. There was an additional 30 cm cut extending across the middle of the torso anteriorly and two more cuts on the anteromedial aspect of the lower legs, set symmetrically (about 23 and 25 cm long). These three cuts were more shallow than the upper extremity wounds. No hesitation wounds were identified. Toxicological analysis identified MDMA (ecstasy). The cause of death was exsanguination. The deceased has been using ecstasy for the previous five years and had a history of inpatient psychiatric treatment due to psychosis with delusions and hallucinations. These self-inflicted incised wounds had many atypical features: location (torso, legs and arms), longitudinal orientation and symmetrical distribution, absence of hesitation injuries, use of both dominant and non-dominant hand. The absence of previous suicide attempts and suicide note suggest that these self-inflicted injuries were not planned beforehand, but were abrupt. We hypothesize that this injury pattern is associated with both acute and chronic effects of MDMA.

Knife cut marks inflicted by different blade types and the changes induced by heat: a dimensional and morphological study

Detailed information on skeletal trauma analysis of burned bone is important to ascertain the manner and cause of death in forensic casework. This research used three different knife types, one with a non-serrated blade, one a fine-serrated blade, and one a coarse-serrated blade, to inflict trauma to manually macerated Sus scrofa ribs (n = 240), and these ribs were later exposed to heat. Qualitative and quantitative analyses were conducted using macroscopic and microscopic techniques to assess specific characteristics of the cut marks. Differences in cut mark dimension and morphology of the ribs were investigated. After heat exposure, the cut marks on the rib samples remained recognisable and did not alter considerably. A level of dimensional and morphological preservation was reliant on the cutting action and the features of the knife blade as well as surrounding bone injury. The cut marks inflicted by the non-serrated blade remained recognisable despite exposure to the burning process. However, the cut marks inflicted by the coarse-serrated blade were likely to change significantly when exposed to heat. This study leads to two important results: (1) identification of pre-existing cut marks prior to heat exposure is possible in reconstructed burned bone fragments, and (2) cut marks from different types of knife blades showed dissimilar responses to heat. The outcomes obtained in this study stressed the need to adopt great care with the effects of heat on skeletal trauma analysis.

Fatal suicidal injury of a radiocephalic arteriovenous fistula

A 59-year-old man was found dead in his living room. His body was covered with blood, but the only injury found was a 31-mm-long, transverse incision on the radial surface of the left forearm. Autopsy revealed that the injured vessel was an enlarged cephalic vein from a radiocephalic arteriovenous fistula (RC-AVF) that had been created 23 years before for hemodialysis. Cephalic vein injury is usually not fatal, but circumstantial evidence, autopsy, and histological findings suggested that hemorrhagic shock and death occurred within a short time after the self-inflicted incised wound. This may be explained by the blood flow rate in the RC-AVF, which can reach 12 ml/s; this is 25 times higher than the normal cephalic vein blood flow.

Sharp force fatalities: Differentiating homicide from suicide through a retrospective review (2012-2019) of autopsy findings in Lisbon (Portugal)

Sharp force fatalities may have a homicidal, suicidal or accidental manner of death. To aid in such differentiation this study aimed to identify medico-legal elements which were predictors of a given manner of death as well as to describe the characteristics of these deaths. A retrospective review was performed on all homicides and suicides due to sharp force injury admitted at the South Branch of the National Institute of Legal Medicine and Forensic Sciences between January 2012 and December 2019. Deaths with a performed external examination or forensic autopsy and with available demographic, circumstantial or necroscopic information were included. Each case was reviewed to collect said information and inferential analysis was employed with both parametric and non-parametric tests as well as binary logistic regression to identify independent predictors, with significance defined at α = 0.05. A total of 57 homicides and 20 suicides were identified, with the obtained demographic and circumstantial profile of the homicide victim being that of a young foreign male whose body was found outside home, with no weapon nearby and without a known psychiatric background. Homicides presented more prominently stab wounds, with these being conspicuous on the thorax and neck. Conversely suicides notably presented cut wounds, being critically present in the neck and upper limbs. Oblique thoracic stab wounds conveyed a homicidal death. Other findings that suggested homicide included the presence of clothing damage, additional traumatic lesions and injured lungs or bone/cartilage. Toxicologically, alcohol presence was associated with homicides while psychiatric drugs suggested suicide. The logistic regression identified the presence of additional traumatic lesions (OR 14.8, p = 0.032) and the absence of lethal neck (OR 0.109, p = 0.043) and lethal upper limb (OR 0.022, p = 0.015) wounds as independent autopsy predictors of a homicidal death. However, no single feature is infallible in establishing manner of death. To achieve a cogent conclusion, all investigative elements must be considered while attending to the specifics of each case.

A rare suicide case involving fatal bleeding from varicose veins

This case report deals with a sharp force suicide case, which may challenge the experience of many forensic pathologists as well as the studies published to date. An overview of the published cases shows that sharp force suicides account only for 1.6%–3% of all suicides and the self‐inflicted injuries are usually localized on the body parts easily accessible with one's hand including the neck, thorax, or upper extremities, as well as in locations of major vascular bundles or vital organs. Reported, however, is a case in which the victim relied on the knowledge of her medical condition and used a kitchen knife to incise her varicose veins, which resulted in fatal bleeding. The case is rare on a number of grounds: incision of varicose veins is rarely the method of choice in suicide cases, injuries of peripheral veins are rarely fatal, and so are injuries of isolated veins where no damage to arteries is suffered.

A bizarre case of fatal main renal artery partial laceration without primary kidney injury due to a single stab wound in the chest

Reno-vascular injuries are a rare type of renal injury, and their second most frequent cause is penetrating wounds. The majority of the reports and of the studies are present in the urological and radiological literature and they focus on the clinical approach to such injuries. In the case here presented, an 18-year-old male died after being stabbed in the left hemithorax. During body examination, thoracic organs were found to be unremarkable (except for a small peripheral laceration of the left lung), but the diaphragm was transfixed and the upper wall of the left main renal artery was lacerated. The adjacent renal vein, the kidney, the aorta, the vena cava and the surrounding internal structures were not damaged (except for a small laceration of the pancreatic tail). A massive haemothorax and a large retroperitoneal haematoma in the left kidney area were observed. The cause of death was attributed to haemorrhagic shock following a partial laceration of the left main renal artery due to the stab wound to the chest. No other cases of similar fatal renovascular injuries due to stab wounds have been published in the current forensic literature.

An evaluation of human stabbing performance to inform the standardisation of textile damage examinations: Do simulation trials correlate to reported stabbings?

Forensic textile damage examinations are commonly requested in cases such as stabbings. These requests often involve the testing of knives or other weapons submitted to determine if they could have caused the damage to the evidential garment. Currently a forensic practitioner conducts this testing by manually performing the stabbing action. A biomechanics performance trial was conducted to evaluate how a range of human factors contribute to the creation of textile damage by stabbing actions. Surveys of sharp force fatalities and clinical penetrative injuries reported the chest and abdomen as the most frequent target location for stab wounds. The location of the cut-type damage recorded during the trial was found to correlate to the location of stab injuries incurred during actual stabbing cases. The type of weapon had an impact on the actions undertaken. Participants mostly utilised the smaller utility and hunting knives in underarm thrusting or overarm hacking actions, whereas an overarm hacking action, or combined hacking/slashing action was performed when using the machete. The familiarity of the knife, shape of the handle and perceived risk of injury determined how the handle was held. Participants frequently stabbed into the target immediately in front of their dominant hand, however care should be taken in interpreting this in a casework scenario. The machete was used with the highest mean velocity, and the utility knife the lowest.

Criminological and Medico-legal Aspects in Homicidal and Suicidal Sharp Force Fatalities

The interpretation of sharp force fatality dynamics may be difficult in some cases, but a contribution to analysis of the phenomenon may be provided by case studies. Therefore, the purpose of our study is focused on identifying, in observed sharp force fatalities, reliable parameters that can differentiate a homicidal and suicidal manner of death, with particular reference to criminological parameters. Data derived from sharp force fatality cases in Padua and Venice from 1997 to 2019, anonymized and collected in Excel, included personal, circumstantial, clinical, and psychopathological-criminological data, as well as crime scene investigation, necroscopic, and toxicological data. Statistical analyses were performed using chi-square and Wilcoxon rank-sum tests. Possible predictors of homicide were analyzed by logistic regression. Six parameters (bloodstains distant from the body, clothing lacerations, hesitation/defense wounds, number of injuries, and potential motives) were significantly different in the two groups (p < 0.05). An independent statistical association between potential motives explaining the crime (p < 0.001; OR 27.533) and homicide on multiple logistic regression analysis was highlighted. The absence of clothing lacerations was inversely related to homicide (p = 0.002, OR 0.092). To the best of our knowledge, this is one of very few Italian studies concerning the differential diagnosis between homicidal and suicidal sharp force fatalities. The dynamics of the event is established in most cases by the integrated evaluation of data from crime scene investigation and the autopsy. Nevertheless, in an atypical scenario, a psychopathological-criminological analysis may provide essential elements, and particular attention should be given to the identification of potential explanatory motives.

A Case of Multiple Self-Inflicted Stab Wounds of the Neck Captured on Surveillance Video

Multiple sharp force injuries in a victim make it difficult to distinguish between homicide and suicide. Forensic pathologists also may be unable to determine the total survival time and the survival time with physical activity due to lack of evidence. The authors report here on a case of nineteen stab wounds of the neck, which led to an initial suspicion of homicide. The scene was however captured on surveillance video, which provided a precise description of the wound mechanism and led to the injuries being reclassified as suicidal. No other description of a suicide with such a high number of severe stab wounds has been documented in the literature. The video footage provided additional information concerning survival time. Physical activity was well documented during at least 4 min after the last stab wound and the total survival period was at least 6 min, despite the perforation of both jugular veins and the trachea. Vein injuries are less rapidly lethal than artery injuries. Injuries of the major airways are not immediately lethal and do not lead to immediate incapacitation. The benefit of the video evidence is to highlight wound features that may suggest a suicidal manner and inform forensic pathologists about survival intervals after severe stab wounds to the neck.

Sharp Force Homicide in Denmark 1992-2016

Sharp force trauma is a common homicide method. The weapon is typically a knife, which is easily accessible and does not require special skills. We have analyzed all 471 sharp force homicides in Denmark during 1992-2016 with special focus on aspects that are relevant to forensic pathologists, including the distribution of wounds and organ injuries. Most homicides were committed inside with a kitchen knife. The front left thorax was the most common area to be affected by sharp force trauma. In 18.9% of the victims, there was only one sharp injury, the majority on the thorax. The most common trajectory for stab wounds was directly posterior with no deviation to the sides or up/down followed by directly anterior. The heart (including pericardium) and lungs (including hemo- and pneumothorax) had injuries in more than 75% of the victims. 67% of victims were males. Female victims had more sharp force injuries and defense wounds than male victims. Most females were killed in domestic homicides (73.7%), most commonly in partner killings (56.4%). In contrast, many male victims were killed in a setting of nightlife/intoxication (34.0%) most by a friend/acquaintance delivering a few stab wounds. The results clearly show strong sex differences in both victims and offenders. This could be useful for shaping policies and public opinion, and as a route for understanding the developments in interpersonal violence. In the narrow setting of death investigation, our results will provide an evidence-based approach to understanding the injury patterns in sharp force homicide.

Death due to severe blood loss following an accidental lesion to the femoral vessels

Deaths from sharp force injuries are a significant cause of violent death. While homicides and suicides caused by sharp force wounds are common, accidental injuries are less often described in forensic literature, so their actual incidence or prevalence is not known. This paper presents an accidental death due to massive blood loss which resulted from lesions to the left femoral vessels by glass fragments. The body was found in a pool of blood surrounded by hundreds of glass fragments. Autopsy revealed a near-total transection of the superficial femoral artery, and two wounds of the superficial femoral vein. In case of accidental sharp force injuries, a thorough medico-legal process, including death scene investigation, autopsy examination and toxicological analyses, is always necessary to determine the manner of death.

"Defense" type wounds in suicide

"Defense" type wounds are sustained when a victim is attempting to ward off an attacker, or a weapon. A 39-year-old woman is reported who was found deceased with incised wounds to the dorsa of both hands that resembled defense wounds. Examination of the flexor surfaces of both wrists, however, revealed horizontal incised wounds typical of self-infliction. Perfusion of the subclavian arteries produced leakage of water from peripheral veins within wounds on both hands and the right wrist. Death was due to exsanguination from incised wounds of the hands and right wrist; manner suicide. This case demonstrates the difficulties that may arise in differentiating self-inflicted from assaultive wounds. On occasion suicidal sharp force injuries may be multiple and in atypical locations. In these circumstances a high index of suspicion for homicide must be maintained.

Alteration of the Death Scene After Self-stabbing: A Case of Sharp Force Suicide Disguised by the Victim as a Homicide?

This paper reports a case of a 72-year-old woman who was found dead in her bedroom with a 4 cm vertical stab wound in the abdomen. A bloodstained knife was found in the top drawer of her bedside table. The clothes worn by the victim showed no damage. A bloodstained vest and a sweater with frontal incisions were found far from the victim, in the bathroom and in the bedroom respectively. Several bloodstains were found in every room of the apartment. The evidence found during the forensic examination and, in particular, the Bloodstain Pattern Analysis, led the investigators to determine the manner of death, being consistent with a suicide with a long-lasting physical activity after self-stabbing. This report describes an unusual case of "disguised suicide," in which the victim tried to cover-up the suicide by changing her clothes and concealing the weapon, in the last minutes of her life.

Bony injuries in homicide cases (1994-2014). A retrospective study

Even when human skeletal remains are found in contexts indicative of body disposal after homicide, none of the bones may manifest injuries. When skeletons are incomplete, there are two possibilities, the injured bones are missing or none were injured. This leads to the question how frequently bones are injured during homicide, where the injuries tend to be placed, and whether the frequency of injury is related to the type of homicide. To answer these questions, the postmortem reports from all autopsies performed for homicide victims at the Institute of Legal Medicine at the University Hospital in Frankfurt am Main, Germany, between 1994 and 2014, were retrospectively evaluated for bony injuries discovered during autopsy. In 90 cases, a preliminary postmortem computed tomography (pmCT) examination had been performed. The cases were categorized into the following five groups by type of fatal trauma: blunt force, sharp force, gunshot injury, strangulation, or other. In total, the postmortem reports for 897 homicides (527 male, 370 female) were evaluated. The number of victims per trauma category were sharp force, 309; blunt force, 179; gunshot injury, 242; strangulation, 92; and other, 75. Bony injuries had been reported in 70.9 % of the homicides. The "gunshot" category contained the highest proportion of victims with bony injuries (92.6 %). With 80.4 %, the second-highest proportion of victims with bony injuries was in the "blunt force" category, followed by 66.3 % of victims in the "sharp force" group. In contrast, with 53.3 %, the second-lowest proportion of victims with bony injuries was in the "strangulation" category, which contained a preponderance of female victims, followed by 17.3 % of victims with bony injuries in the "other" category. Bony injuries thus occurred in the majority of homicides. Forensic osteological analysis should, therefore, always be performed on badly decomposed human remains. Where necessary, the additional use of visualization techniques, in particular, pmCT, or maceration may be considered. The absence of bony injuries does not rule out homicide; e.g., in strangulations, bony injuries are manifest in only half the victims, even when the skeleton is intact. The relevant structures are also easily lost to decomposition, scavenging, or scattering.

A Retrospective Study of Blade Wound Characteristics in Suicide and Homicide

The distinction between self-inflicted blade wounds and blade wounds inflicted by another can be difficult in situations where there is little available history or context. We reviewed homicides and suicides in the past 10 years at the Vermont Office of the Chief Medical Examiner to define the characteristics of homicidal and suicidal blade wounds. All homicides and suicides involving blade wounds, not just those in which blade wounds were the cause of death, were included. Information regarding victim demographics, location and type of injuries, toxicology, and evidence of suicidality was gathered. Blade wounds were the cause of death in 85.7% of homicides but only in 36% of suicides. Hanging and gunshot wounds were the cause of death in 28% and 24% of suicides, respectively. Multiple stab wounds were found in 10% of homicides and in 0% of suicides, whereas multiple incised wounds were found in 60% of suicides and only 10% of homicides. However, several unusual instances of suicide were found, including suicides with clothing damage or bone or cartilage injury from blade wounds. No characteristics of blade wounds were definitive for homicide or suicide. History and circumstances of the scene are thus crucial in determining the manner of death.

Undetected patricide: Inaccuracy of cause of death determination without an autopsy

Patricide (killing the father) is uncommon form of homicide. Usually the assaults occur at home in the absence of witnesses and adult sons are frequently involved. Homicides in a domestic context usually do not tend to recurrence, because the motivation for the crime ends with the death of the parent. However, this is not what was observed in the present case study dealing with the death of a 70 years old white man originally misclassified as accident and discovered three years later only after an additional homicide in a family context of a 60 years old white lady. Multiple stab wounds to the neck and thorax were misinterpreted at the external male body examination as blunt trauma falling down stairs. No forensic autopsy was requested and no comparison of medical findings with the results from the death scene, such as a bloodstain analysis was performed by the police officers nor required by the judicial authority. This was quite surprising because an additional but preliminary post-mortem external examination performed by a general practitioner on the male body already raised the suspicion that the external lesions were stab wounds thus requiring a forensic autopsy. Only the exhumation of the elderly body, performed years later, confirmed the diagnostic hypothesis raised by the first physician. The present case is quite representative of a death investigation not run professionally and performed by individuals with no specific training where most of the medico-legal investigations (especially for traumatic and violent deaths) are restricted to an external body examination without subsequent autopsy. Although misinterpretation of external lesions is inevitable and significant discrepancies between external body examination and forensic autopsy are not rare, in the case of contradictory results of post-mortem external examination or unclear/suspicious cause and manner of death, investigation should proceed necessarily with a forensic autopsy.

Discriminating factors in fatal blunt trauma from low level falls and homicide

PURPOSE

Determination of the manner of death is a major issue in forensic practice. Differentiating the injuries caused by falls from a low height from injuries due to the deliberate application of a blunt object can be difficult. A few studies suggested the use of certain criteria, such as the hat brim line rule, to help in differentiating between falls and blows. Unfortunately they are not consistent.

METHODS

All autopsy cases from a 16-year period (1996-2012) were analyzed retrospectively. Three groups were defined: homicide cases (n = 31), sudden natural deaths involving a fall (n = 103), and accidental fall cases (n = 30). The three groups were statistically compared across a wide range of parameters including general characteristics, presence, and characteristics of different types of wounds (lacerations, deep bruises, fractures, intracranial trauma, and defense injuries) as well as their respective anatomical site.

RESULTS

There were marked differences in wounds between homicide and fall cases, e.g., wounds were more numerous and larger in homicides. We did not confirm the hat brim line rule as a reliable discriminating parameter. A simple and highly effective multivariate model was found, which included the presence of lacerations, deep bruises, and intracranial trauma.

CONCLUSION

This study underlines the importance of autopsy findings in providing an indication of the manner of death. Conversely, the limitations of the hat brim line rule have been highlighted.

Survival time estimation using Injury Severity Score (ISS) in homicide cases

The aim of our study was to assess the value of ISS to estimate survival time in a retrospective study of all homicidal deaths in the Western suburbs of Paris between 1994 and 2008. Stab wounds were the most common cause of death. Survival time between assault and death, determined in 107 cases out of 511 homicide cases, ranged from 0 min to 25 days (mean 39 h). There was an overall significant association between the survival time and the ISS score. ISS and survival time were strongly associated with male victims and a clear trend was seen with women. Regarding the type of wounds, a trend was seen with gunshot wounds and blunt injuries, but not with stab wounds. There was no influence of blood toxicological results and resuscitation attempts. Overall, ISS was a good predictor of a survival under 30 min.