Forensic pathological study of complex and complicated suicides: A twelve-year case series in Genoa (Italy)

A case report of complex suicide in physician: attempt drugs poisoning and adhesive tape asphyxia

Complex suicides are rare occurrences that can be categorized into planned (or primary) cases and unplanned (or secondary) cases. Additionally, individuals often select suicide methods based on their availability and accessibility. The body of a 58-year-old man was discovered deceased inside his medical office. He was found seated on the waiting room sofa, with his airways obstructed by several layers of adhesive tape wrapped around his head. An intravenous needle was observed in his left arm, and on the table in front of him, an empty 50 ml syringe, two empty vials of 10 ml potassium chloride, and an empty 10 mg vial of Valium (diazepam) were found. A roll of adhesive tape, similar to the one around his head, was also present. The autopsy, conducted 36 h after the body's discovery, revealed therapeutic concentrations of diazepam and its metabolite nordiazepam in the blood samples, while potassium chloride was not detected. Integrating forensic findings obtained from autopsy, histology, and other postmortem investigation, including toxicological analysis, can aid in defining suicidal behavior and preventing misinterpretation, particularly in differentiating diagnosis between homicide and suicide. It is crucial to consider circumstantial data and professional knowledge in such cases.

Forensic remarks regarding 35 cases of complex suicides and 4 cases of complicated suicides investigated at the Institute of Legal Medicine of Brescia during the period 1983-2022

The role of the forensic pathologist is central to both identifying the cause and determining the manner of death. Distinguishing a suicide from a homicide or accidental event is essential to define whether third parties are involved in death. Suicides are most frequently performed using a single method; therefore, they can be defined as simple. The term "complex suicide" refers to a form of suicide in which two or more methods are applied by the victim, simultaneously or in chronological succession, to achieve the death. The different methods may have been planned in advance to prevent failure of the first method or may occur because the first method was not effective or was too painful, so the victim quickly seeks another way to complete the suicide. "Complicated suicides", on the other hand, are characterised by an unintentional secondary trauma following the suicidal act. This study analyses 35 complex suicides and 4 complicated suicides investigated at the Institute of Forensic Medicine in Brescia (Italy) during the period 1983-2022. Some data about the cases are discussed. This study aims to demonstrate how multiple lesions on the victim's body are not in themselves indicative of the intervention of third parties in their production, but complex and complicated suicides must always be considered.

Suicide, depression and thyroid dysregulation: An unusual case of unplanned complex suicide

Complex suicides are rare events pursued by the victims by means of two or more different fatal methods and can be further classified in planned or unplanned depending on the simultaneous or sequential application of the methods, respectively. The multiplicity of the injuries detected can frequently lead to misinterpretations, thus making a multidisciplinary approach of utmost importance. Here an unusual unplanned complex suicide was described discussing the post-mortem data leading to the forensic diagnosis; moreover, a focus on the depression cause was reported. The case regarded a 48-year-old man with a recent diagnosis of depression who self-stabbed his neck and, subsequentially, fallen from height. Data obtained from autopsy, histology, radiology and toxicology were described, highlighting the main findings for achieving the differential diagnosis between suicide and homicide. Moreover, microscopic findings compatible with an unrecognized thyroiditis led to consider the thyroid dysfunction as a possible substrate of depression, suggesting it potential effect on suicidal behaviour.

Complex (Multimodality) Suicides in New York City: 2008-2017

ABSTRACT

Complex (or multimodality) suicides pose a challenge for forensic pathologists, because they are infrequent and can be mistaken for the more frequent multiple-injury homicides. Complex suicides are suicides in which 2 or more self-inflicted injurious modalities are used. Among all suicides, this specific type has an incidence of 1.5% to 5%. 1 Few publications exist that examined complex suicides, with the largest review discussing only 19 cases. 2,3 To address the need for better characterization of complex suicides, a 10-year retrospective review was conducted of the database of the New York City Office of Chief Medical Examiner. This is the largest case review to date, with 93 complex suicide cases studied and the first American study contributing to this field. Results provide information regarding the demographics of decedents, incidence of mechanisms used, and mechanisms used in series. Results show that in New York City (NYC), complex suicides predominantly include asphyxia, blunt trauma, and drug toxicity. In addition, suicides in NYC occur at a similar incidence to their US national incidence, and demographics of decedents and most common injury mechanisms mirror those of simple suicides in NYC. However, injury mechanisms do not mirror those that are most common nationally. This contrasts with published data and provides a novel insight into suicide modalities in NYC.

A rare case of complicated suicide: Self-immolation and subsequent stab heart injury due to fall into a glass door

Complicated suicides can be defined as incidents where death is caused by a subsequent trauma rather than the primary injury. Deaths which occur as a complication of the suicidal act are very rare with few reports in the literature. We present the case of a 60-year-old man who was found at his home while still alive. His body was burning and he was lying on his back impaled by shards of glass that had come from a broken glass door. An ambulance was called but the man died before arrival at hospital. The autopsy showed stab heart and lung injuries in thorax and an abdominal stab trauma which resulted in the protrusion of the small intestine. Homicide was excluded and the sequence of events was reconstructed to reveal a complicated suicide intended to result from self-immolation but which resulted in a fall against a glass door which in turn resulted in shards of glass piercing his body and a fatal stab wound to the heart.

Postmortem forensic toxicology cases: A retrospective review from Milan, Italy

We are presenting a study on 136 cases performed in a 2-year period (2018-2019) at the Bureau of Legal Medicine of the University of Milan for which toxicological analyses were requested and we are making a detailed interpretation of clinical records and discussing toxicological results from each case included in the study. Total number of autopsies was 1323 and in 10.3% of the cases, toxicological analyses were requested to obtain further information. Analyses were assessed with High-Performance Liquid Chromatography-Mass Spectrometry system and Gas Chromatography-Mass Spectrometry analyses. Additionally, Blood Alcohol Concentration and detection of volatile substances were obtained with Head Space-Gas Chromatography-Mass Spectrometry system. From these analyses, 101 cases out of 136 provided positive results (74.3%). Main substances detected were cocaine, diazepam, morphine, and ethanol. The most representative profiles of individuals that emerged from this study were: a Caucasian male, age 41-50, that died for cocaine acute intoxication or was killed; a Caucasian male or female with a range-of-age of 31-50 deceased for simple suicide caused by acute intoxication or by complex suicide caused by acute intoxication and suffocation; and finally, a Caucasian male with a range-of-age 21-40 that died in a car accident without any toxicological evidence. From the results, acute intoxication at the time of death was confirmed in 54 cases and in 57 cases the toxicological analyses helped in the determination of the cause and manner of death. From this study, the importance of toxicological data among forensic sciences is confirmed.

Complex suicides: 21 cases and a review of the literature

Background

The use of more than one potentially lethal method together and sequentially to complete suicide is called “complex suicide.” Complex suicides are divided into two groups: planned and unplanned. This study aimed to discuss with literature 21 complex suicide cases identified after a 2-year retrospective study.

Results

This study included 21 complex suicide cases. Eleven were classified as planned complex suicides, and 10 were labeled as unplanned complex suicides. The average age of all cases was 42.5 ± 17.7 (min: 19, max: 76) years. Suicide notes were present in six (28.5%) cases. Fifteen victims (71.4%) suffered from psychiatric diseases. Twelve victims ingested a toxic dose of medication, nine cases jumped from a height, eight cases used stabbing, six cases used hanging, two cases ingested a corrosive substance, two cases drowned, two cases inhaled a toxic gas, one case ingested cyanide, one case ingested insecticide, and one case used suffocation with a plastic bag. In two cases, three methods of suicide were used together. In the current study, “corrosive substance intake + cyanide intoxication” and “corrosive substance intake + jumping from a height” were defined for the first time and have not been previously described in the literature.

Conclusions

Complex suicides are highly likely to be potentially mistaken for murder. The cause of death in these cases can be determined with a comprehensive autopsy along with a detailed examination of the scene, statements of relatives, and eyewitnesses.

A Rare Case of Fatal Self-Poisoning With Sodium Nitrite: Autopsy and Toxicological Findings

ABSTRACT

Fatal sodium nitrite poisonings are unusual in the forensic setting. Suicide by poisoning includes drug overdose, the inhalation of toxic gasses, and poisoning from pesticides and chemical substances. Sodium nitrite is an inorganic compound usually seen as a crystalline powder that is very water soluble. Sodium nitrite is used mostly in the food industry (as a preservative) and in medical field (as an antidote to cyanide poisoning), and if ingested in large enough amounts, it can be fatal.The ingestion of sodium nitrite can cause severe methemoglobinemia, which is a metabolic disorder characterized by an inability of hemoglobin (which gets oxidized into methemoglobin) to bind (and therefore carry) oxygen. Severe cases of this condition, if not treated, can be fatal.We describe a case of fatal self-poisoning with sodium nitrite; in particular, the article focuses on the autoptic and toxicological investigations that enabled the correct diagnosis to be established.

Planned complex suicide involving combined drug intoxication and femoral catheterization

Complex planned suicide is characterized by the simultaneous use of two or more methods to ensure that death occurs even if one method fails. The authors present an original combination of two self-killing methods. A 42-year-old cardiologist, with a major depressive syndrome and several suicide attempts, as well as cocaine addiction, was found dead at his home with a femoral catheter inserted in the right femoral artery. The autopsy concluded that death was due to major hemorrhagic process in a context of suicide. Toxicological analyses, performed in peripheral blood by gas chromatography coupled to mass spectrometry and by liquid chromatography-diode array detection, revealed the presence of ethanol (0.13 g/L), cocaine, and metabolites (cocaine: 432 µg/L, benzoylecgonine: 3286 µg/L, ecgonine methyl ester: 1195 µg/L, cocaethylene: 41 µg/L), a potentially lethal concentration of citalopram (1.03 mg/L), toxic concentrations of hydroxyzine (0.11 mg/L), bromazepam (2.06 mg/L), and lidocaine (7.30 mg/L). At the end of these analyses, the death was reclassified as planned complex suicide combining drug intoxication and catheterization of the femoral artery. The authors discuss the main aspects of this case and stress the importance of meticulous analysis of all available evidence: witness reports, victim's medical history and occupation, findings of at-the-scene examination, autopsy, and toxicological analyses, in order to exclude homicide and to understand the sequence of events that led to death.

Complex and complicated suicides in Friuli (1993-2017)

Complex suicides involve more than one suicide method. According to the intention of the victim, they are classified as 'planned' when the use of more than one suicide technique has been previously devised by the victim and 'unplanned' when the first method turns out to be too painful or insufficient to cause death, and the individual then resorts to other means of suicide. Complicated suicide, on the other hand, is a term that was introduced by Töro and Pollak, in which a failed act of suicide is followed by traumatisation, which has a fatal outcome. This type of death must be distinguished from complex suicides. From a sample of 1160 fatalities (837 males) between 1993 and 2017, we identified 20 (1.72%) cases of complex suicide and three (0.26%) cases of complicated suicide. We considered age, sex, psychiatric history, previous suicide attempts, suicide methods and eventual secondary traumatisation. We also compared planned and unplanned complex suicides. The results show a higher number of planned complex suicides (16 vs. 4), a prevalence of males (n = 17) and adults (median age = 48 years, range 21-74 range). Plastic bag suffocation and gas inhalation (n = 8) were the most commonly used methods. Firearms (n = 4) were used exclusively by males in planned complex suicides. Wrist and forearm cuts (n = 5) were found in four unplanned and one planned complex suicides, and all of the cases with known previous suicidal attempts (n = 3) involved planned complex suicides. Complicated suicides concerned three male victims in two failed attempts of hanging and an unforeseen carbon monoxide intoxication following a non-fatal gunshot to the mouth, confirming the rarity of these fatalities.

A forensic analysis on 53 cases of complex suicides and one complicated assessed at the Bureau of Legal Medicine of Milan (Italy)

Complex suicides are highly uncommon suicides in which multiple detrimental methods are used simultaneously or in chronological succession. We retrospectively analyzed through our database the 25512 autopsy reports registered at the Bureau of Legal Medicine of Milan in the last 27 years from 1993 until 2019, where 4498 suicides were documented. We assessed 53 cases of complex suicides and only one case of complicated suicide: for all of them we analyzed both data collected during the on-site investigation and the autopsy. In our case series, we identified a total number of 113 methods chosen and variably combined by the victims, which were classified into 17 categories. On the whole the most frequent association of suicide methods resulted in the combination of the plastic bag suffocation with inert gas inhalation (13 out of 53 complex suicides; 24.5%). We also analyzed our cases of simple suicides (1993-2019), to compare them with the complex suicides. In this study, we present a complete analysis regarding our cases of complex suicides, discussing the challenges and the interpretative issues which a forensic pathologist might deal with. A thorough on-site judicial inspection and a careful autopsy examination are crucial in such cases. Moreover, the clinical history of the victims and laboratory findings are supplemental elements to be necessarily considered to establish the actual manner of death and avoid any misinterpretations.

Forensic Pathological Considerations of a Unique Case of "Complicated Suicide"*,†

In the forensic literature, peculiar and uncommon cases of suicides defined as "complicated" are reported. In these circumstances, the suicide method chosen by the victim fails, and death occurs due to a subsequent unforeseen accidental event defined as secondary trauma. Through retrospective examination of 25,512 autopsies in 27 years (1993-2019) at the Bureau of Legal Medicine of Milan, a unique case of complicated suicide was identified from a total of 4497 suicides. It concerns an elderly man who, after killing his wife by inflicting incised wounds to her neck, tried to hang himself by tying a rope to a heater and jumping from the window located over the heater itself. However, the rope suddenly snapped and the man fells to the ground causing fatal traumatic injuries. Death occurred because of an accidental event caused by the failure of the hanging mechanism. Therefore, a peculiar yet characteristic case of complicated suicide is described.

A burned body with a gunshot wound in the mouth and a suicide note: A complex or complicated suicide?

The body of a 53-year-old man was found in a burning car. The ignition key was in start position and the accelerator pedal was held down by his right foot. Autopsy revealed a gunshot entrance wound in the hard palate, a bullet track through the anterior cranial fossa and a projectile lodged in the left frontal lobe. The brain stem was free of lesions and any signs of secondary brain injury, such as brain oedema and intracranial haemorrhage, were not significant. Soot deposits and thermal injury to the mucosa were observed in the airways below the glottis and carboxyhaemoglobin (COHb) saturation was 40%. A single bullet case and a handgun were recovered next to the driver's seat. Fire investigators identified the motor as the beginning of the burning: therefore, the conclusion was that the car had caught fire due to overheating of the engine. Differential diagnosis between complex and complicated suicide was essential. The cause of death was identified as carbon monoxide intoxication, and the injuries to the brain were not felt to be immediately fatal. The case has been classified as a complicated suicide. There are no other published cases of a complicated suicide involving exposure to fire or the use of firearms.