Complex suicides--a review of the literature

The term "complex suicide" stands for suicides committed by using more than one method. A distinction can be made between planned and unplanned complex suicides (primary/secondary combinations). In planned complex suicides 2 or more methods are applied simultaneously in order to make sure that death will occur even if one method fails. In unplanned complex suicides the mode of performance is changed after the first method chosen failed or was working too slow or proved to be too painful. In planned complex suicides typically two of the generally common methods of suicide (e.g. ingestion of medicines, hanging, use of firearms, drowning, fall from a height) are combined. But also unusual combinations have been described such as the simultaneous firing of two guns, self-immolation in combination with other suicide methods or shooting oneself while driving a car. In unplanned complex suicides self-inflicted injuries by sharp force, especially cuts of the wrists, are often found as the primary act of suicide. In some cases the suicide switches from cuts to stabs (mostly to the heart region). Other methods often used after the first phase of suicide are hanging and jump from a height. In the literature the use of up to 5 suicidal methods applied one after the other have been described.     

The characteristics of head wounds inflicted by "humane killer" (captive-bolt gun)--a 15-year study

The "humane killer" or captive-bolt gun, is the tool/weapon widely used in meat industry and private farmer households for slaughtering animal stock. Out of 17,250 autopsies performed at the Institute of Forensic Medicine in Novi Sad during the 15-year period (1991-2005), 29 cases of suicides and two homicides were committed by captive-bolt pistols. Wounds inflicted by captive-bolt guns have specific morphological features, distinctive from wounds made by other kinds of hand firearms. Selected features of the captive-bolt wounds (punched round entrance and a double pattern of smoke soiling) depend on distance and angle of instrument at the time of firing. Autopsy findings were compared with an experimental model consisting of 20 domestic pigs. Obtained results confirmed that the appearance of the entrance hole and soot deposits, along with differences in shape, location, extent, and density of soot blackening, could be useful in identification of weapon, direction of discharge, shooting distance, and angle of the muzzle to the frontal and sagittal planes of the head at the moment of fire.     

Clinicopathologic features of fatal self-inflicted incised and stab wounds: a 20-year study

The files of the Forensic Science Center in Adelaide, South Australia, were examined for all cases listed as suicide in which death had been caused by the use of a sharp instrument during the 20-year period from January 1981 to December 2000. Fifty-one cases were identified, consisting of 35 men and 16 women. The age range was 23 to 83 years (mean 49 years) representing 1.6% of total suicides (513182). Fatal injuries included incised wounds to the arms in 51.4% of men (n = 1835) compared with 87.5% of women (n = 1416), incised and stab wounds to the neck in 40% of men (n = 1435) and 25% of women (n = 416), and stab wounds to the chest or abdomen in 28.6% of men (n = 1035) and 12.5% of women (n = 216). In 8 cases, multiple sites were involved. The use of sharp instruments in suicide was favored by older, rather than younger, individuals, with a tendency for women to incise their wrists. Hesitation marks were present in 23 cases (54%) and scarring of the wrists from previous suicide attempts in 5 cases. Although this study demonstrated a higher number of men than women committing suicide by using sharp objects, this method of suicide remains uncommon.     

Suicide with two guns represents a special type of combined suicide

Suicide by simultaneous gunshots with two firearms is rare. The case of a 90-year-old man who killed himself with two 6.35 mm pistols fired at the temples at the same time is presented. The victim was found dead on the terrace of his home; two guns and two cartridges were present near the corpse. Cases of suicides with two guns published in the literature are compared, and the Italian cases are illustrated briefly. The authors describe the circumstances and autopsy findings that permitted the assertion that it was a case of suicide and to exclude an homicide and show, by figures, the three-dimensional reconstruction of cranial shooting injuries. The use of two guns is considered a representation of a special type of "combined suicide" or "planned complex suicide."     

Comparison of wound morphology following gunshots by machine guns and sub-machine guns

Automatic weapons such as machine guns and submachine guns are found in the German-speaking region only in special army and police units and appear accordingly rarely in homicides, suicides and accidents. In the following, the findings in two cases of death with the use of machine and submachine guns are presented. The first case was a fatal accident during shooting on a training area (current machine gun of the German army, calibre 7.62 x 51 mm), the second case was a killing during a physical conflict (submachine gun MP 40 from World War II, calibre 9 x 19 mm). In the case with the machine gun autopsy disclosed typical entry holes corresponding to the calibre, but unusually large exit wounds with tissue bridges in the wound ground, measuring 4 x 2.5 cm in diameter. By contrast, the second case (submachine gun) showed "normal" entry and exit wounds. The differences are mainly caused by deviating ballistic data of the ammunition used. They are discussed against the background of literature on wound ballistics.     

Suicide by 120 stab wounds of the chest?

The case history of a suicide due to 120 stab wounds of the chest is presented. The victim was a 41 years old man with a paranoid-hallucinative psychosis. The problem to distinguish homicides and suicides is discussed by the well-known criminalistic and forensic-medical criterias. Induced by this very unusual case the autopsy material with stab wounds was analyzed retrospectively (n = 246, out of about 14,000 autopsies at the Institut of Forensic Medicine in Hamburg). Cases with more than 40 single lesions are normally homicides. However, the pattern of the injuries is more important than the number--especially in doubtful cases.     

Methadone maintenance programs--a two-edged sword?

Retrospective review was undertaken of all autopsies in which methadone was detected at the Forensic Science Centre, South Australia, during a 3-year period from July 1996 to June 1999. Thirty-five cases were found in which methadone had either caused or contributed to death (age range = 14-54 years; average = 31 years; M:F = 3.4:1). Ten victims were participating in a methadone maintenance program, of whom four died within a week of enrollment. Eight victims (23%) not enrolled in a methadone maintenance program were found who had died after the use of "diverted" methadone (i.e., prescribed for someone else) (age range = 14-34 years; average = 25 years; M:F = 6:2). Deaths were directly attributable to methadone toxicity in seven of the eight cases, with additional drugs or alcohol being found in seven cases. Prevention of ongoing deaths caused by methadone diversion could be achieved by allowing only daily releases of methadone, with the addict having to consume the drug under close supervision.     

The forensic deaths caused by pesticide poisoning between the years 2006 and 2009 in Izmir, Turkey

Pesticide poisoning is still a significant health problem in Turkey. We conducted a retrospective study of autopsy cases at Izmir Branch of the Council of Forensic Medicine to describe the characteristics of deaths caused by pesticide poisoning between 2006 and 2009. The distributions of the cases according to gender and age were as follows: men 74.1% (n = 40, mean [±SD] age, 44.7 ± 14.1), women 25.9% (n = 14, mean [±SD] age, 39.2 ± 18.9). The majority of pesticide-poisoning deaths were suicides (n = 43, 80%) followed by accidents (n = 4, 8%) and homicide (n = 1, 2%). The manner of death could not be determined in six cases (11%). Suicides mostly occurred at home (n = 26, 63%) (p < 0.05). Methomyl was the most frequent pesticide (n = 9, 17%) among the all cases. This study reported that most of the pesticides found in poisoning cases were highly hazardous types. Combined efforts of medical professionals and law makers are needed for enacting strict laws against highly hazardous pesticides.     

Female suicides in Diyarbakir, Turkey

The aim of this study was to investigate the methods used and demographic data of women suicides by examining postmortem investigation and autopsy reports from the Branch of the Council of Forensic Medicine in Diyarbakir Province, Turkey, between 1996 and 2001. Fifty-eight percent (174/302) of suicides were females and 42% (128/302) were males. The suicide rates were similarly higher for females than for males (2.6 and 1.8 per 10,000 population, respectively). Over half of female suicides (56.3%) occurred in those under 20 years of age. The most common suicide method for women was hanging (32.2%), and for men was firearms (51.7%), but for women younger than 20 years the most frequent method was firearms. Among the female suicides, five (2.8%) were known to have attempted suicide at least once in the past. Twenty-nine women (16.7%) were documented to have any psychiatric illness. None of the women had a history of drug or alcohol abuse. A suicide note was found in only six cases (3.4%). The predominant suicide motive was family problems (in 32% or 56/174). The higher rate of suicide in females than in males, and the absolute female predominance in suicides in Diyarbakir, Turkey, are in contrast to most of the medical literature and statistical information about suicide rates by country, in which suicide rates are usually higher among males.     

Post-mortem cases involving amphetamine-based drugs in The Netherlands. Comparison with driving under the influence cases

In this study we reviewed the post-mortem cases in the years 1999-2004 that were presented at the Netherlands Forensic Institute. The concentrations of amphetamine-based drugs in femoral blood from cases of suspected unnatural death were compared with concentrations in whole blood from non-fatal cases of driving under the influence (DUI cases) and with literature. Furthermore, the combinations with other drugs and/or alcohol were investigated. Amphetamine-based drugs were present in 70 post-mortem cases and 467 DUI cases. The most detected amphetamine-based drug was MDMA, followed by amphetamine. The presence of MDA could usually be explained by metabolism of MDMA. Methamphetamine and MDEA were rarely present. Frequently, the amphetamine-based drugs were taken in combination with alcohol and/or other non-amphetamine-based drugs such as cocaine or cannabinoids. The 70 post-mortem cases were divided into 38 amphetamine-based drug caused (i.e. the amphetamine-based drug directly caused or contributed to the death) and 32 amphetamine-based drug related deaths (i.e. death was not directly caused by the amphetamine-based drug). In the latter category, other (poly)drug intoxications and death by violence or drowning were the most frequent causes of death. In 30 cases, MDMA caused death directly. The range in blood concentrations of MDMA in these cases was substantial, i.e. 0.41-84 mg/L with a median concentration of 3.7 mg/L (n=30). MDMA blood concentrations in the MDMA related deaths (n=20) and in the DUI cases (n=360) varied up to 3.7 and 4.0 mg/L, respectively. Seven victims died from the direct effects of amphetamine; the blood concentration of amphetamine ranged from 0.24 to 11.3 mg/L, with a median concentration of 1.7 mg/L (n=7). The median concentrations of amphetamine in the amphetamine related deaths (n=13) and the DUI cases (n=208) were much lower, i.e. 0.28 and 0.22 mg/L, respectively. Amphetamine blood concentrations up to 6.0 and 2.3 mg/L were seen in the drug related deaths and DUI cases, respectively. The most frequently encountered amphetamine-based drugs in the investigated deaths were MDMA and amphetamine. The majority of MDMA- and amphetamine-caused deaths, i.e. 90% of these deaths, occurred with blood concentrations above 1.5 and 0.80 mg/L, respectively. MDMA and amphetamine blood concentrations in drug related deaths and DUI cases, however, overlap the range of fatal concentrations. Therefore, MDMA or amphetamine concentrations should never be used alone to establish the cause of death.     

Complex suicides by self-incineration

Among the few cases of suicidal self-incineration primary or secondary complex suicides are a rarity. Accordingly the number of reports on this subject in the forensic literature is small. In a retrospective analysis of the Freiburg and Berlin autopsy material, four cases were found within an observation period of 11 years. These are described together with seven other cases reported in the literature. Altogether most of these suicides are primary combinations, especially with falls from a height. Other combinations include hanging or the infliction of stabs, cuts or gunshot injuries. The sex and age distribution is similar to that found for suicide by self-incineration alone.     

Violence,Guns, and Suicide in New Orleans: Results from a Qualitative Study of Recent Suicide Decedents

Many Americans own guns to protect themselves against other people, but there is evidence that both victimization and gun access increase suicide risk. We conducted qualitative interviews with informants of 17 suicide cases in New Orleans of the 60 who died between January 2015 and April 2016 to understand the relationship between past trauma, gun access and storage, and suicide. Nine cases had experienced a past trauma, including three who had recently had a family member killed by homicide. Eight died via firearm; of those, seven owned the guns they used to take their lives and stored them locked (but loaded) at home or in their cars. Preventing community violence and addressing its sequelae may be important for reducing suicides. A multi‐pronged strategy consisting of policies, education, and marketing will likely be needed to address the risk of suicide conferred by gun access.     

Fatalities in the bathtub

A retrospective analysis concerning deaths in the bathtub was carried out in the Institute of Legal Medicine in Hamburg. The study includes 245 death cases between 1971 and 1988 (1% of all autopsies). 66 cases proved to be natural deaths, 76 were classified as suicides, 39 as accidents and 13 as homicides; 51 fatalities remained unclear with respect to one of these groups. Among the natural deaths sudden cardiac deaths were dominating (n = 39), among the suicides the intoxications (n = 37) and electrocutions (n = 20), and among the accidents the intoxications by carbon monoxide (n = 17) and electrocutions (n = 12). Out of 13 homicides only 2 were committed directly in the bathtub: One by drowning of a child and one by electric current via a hair dryer; in the other cases the dead body was put into the bathtub post mortem. About 50% of the victims were alcoholized. Signs of drowning were present in about 40% of all cases; the most frequent finding was emphysema aquosum.     

Preliminary test with chlorindazone DS for zinc in Sintox residue

So-called exit bags are voluminous, transparent plastic bags, each with a collar to go round the neck, and a Velcro fastening. In conjunction with the consumption of sleeping pills, the bags are recommended as an aid to commit suicide by organizations in favour of "humane death". It is reported on four such suicides by elderly people between 79 and 87 years of age. In two of these cases, there was assistance in committing suicide, one corresponding to a suicide protocol from the Swiss organization for euthanasia, EXIT. In two cases, detailed instructions for committing suicide were found. The morphological findings were not very specific in any of the cases. If the plastic bags are removed by a third party, this type of suicide may remain undetected even after performance of an autopsy. Exit bags tend to be used by older people with either real or feared life-threatening illnesses, in suicides which have usually been planned for some time. From the criminological point of view, the possible active participation of other persons in pulling the covering over the head can often not be proved. Assisting a suicide, in the sense of giving instructions on how to accomplish it, is not punishable in German law.     

The use of emission spectrum analysis in the forensic medical expertise of gunshot wounds (experimental research)

Presents the methodology of experimental shots from various guns (n = 11) by common cartridges and of emission spectral analysis (ESA) which was used to study the regularities in deposition of "gunshot metals" at the site of gunshot injuries and to detect the characteristic differences in shooting with and without obstacles. Effects of some factors on deposition of metal components of gunshot products at the site of gunshot injuries are studied: type of gun, shell (with/without coating or semicoated), presence of obstacles, distance, and order of the shot. Results of studies are presented for some guns, which may be useful in forensic medical expert evaluations by means of ESA.     

Cluster hanging suicides in the young in South Australia

Retrospective review of hanging suicides in individuals aged ≤ 17 years was undertaken at Forensic Science South Australia, Australia, over two 5-year periods: 1995-1999 and 2005-2009. Seven cases of hanging suicides were identified from 1995 to 1999, with a further 14 cases from 2005 to 2009, an increase of 100% (p < 0.001). Hanging accounted for 33.3% of all suicides in this age group (7/21) from 1995 to 1999, compared with 93.3% of the total number of suicides (14/15) in the second 5-year period. In contrast, Australian national data from 1998 and 2008 showed a 30% decrease in hanging suicides in the young, from one case/100,000 population in 1998 to 0.7 in 2008. Cluster suicides occur in the young and are often initiated by direct communication. As it is possible that Internet-based social sites may facilitate this phenomenon, investigations should include an evaluation of the victim's Internet access given the potential risk of similar actions by peers.     

Suicide by asphyxiation due to helium inhalation

Suicide by asphyxiation using helium is the most widely-promoted method of "self-deliverance" by right-to-die advocates. However, little is known about persons committing such suicides or the circumstances and manner in which they are completed. Prior reports of suicides by asphyxiation involving helium were reviewed and deaths determined by the North Carolina Office of the Chief Medical Examiner to be helium-associated asphyxial suicides occurring between January 1, 2000 and December 31, 2008 were included in a new case series examined in this article. The 10 asphyxial suicides involving helium identified in North Carolina tended to occur almost exclusively in non-Hispanic, white men who were relatively young (M age = 41.1 T 11.6). In 6 of 10 cases, decedents suffered from significant psychiatric dysfunction; in 3 of these 6 cases, psychiatric disorders were present comorbidly with substance abuse. In none of these cases were decedents suffering from terminal illness. Most persons committing suicide with helium were free of terminal illness but suffered from psychiatric and/or substance use disorders.     

Suicide among adolescents and young adults

A closer analysis was made of all postmortems at the Benjamin Franklin Campus of the Institute of Forensic Medicine performed on juveniles who committed suicide at the age of 20 or below in the period from 1998 to 2003. A double suicide of a young couple, who met on the Internet and agreed on the procedure to be followed up to the act itself, which took place in Berlin, is presented as a representative case. The authors emphasise that in view of the danger of emulation, the media should exercise restraint in describing concrete details especially when reporting about suicides of juveniles.     

Electrocution--autopsy study with emphasis on "electrical petechiae"

Fatalities caused by electrocution (n = 37) were re-examined on the basis of the autopsy records, the police reports and the technical expertise. Accidents including two lightning deaths caused 2/3rd and suicides 1/4th of the fatalities and there were two homicides. Carelessness or ignorance were a major reason for accidental deaths while technical defects could be verified in five cases only. Low-voltage ac and male victims predominated. Electrical burns or current marks were detected in 81% including all high voltage electrocutions. The seven victims lacking burns were electrocuted in a wet environment including six cases of suicide in the bathtub with a hair drier. Petechial haemorrhages were present in 74% of the cases and the favourite sites were the skin of the eyelids, conjunctivae, visceral pleura, and the epicard. The presence of petechiae did not depend on the voltage or the current pathway relative to the heart. It is, therefore, suggested that the petechiae are not caused by asphyxia but by a combination of venous congestion due to cardiac arrest and a sudden rise in blood pressure induced by muscle contractions. Consequently, "electrical petechiae" represent a non-specific but typical finding in electrocution irrespective of the mechanism leading to death. Unlike electrical burns, petechiae also indicate the vital origin of the events. The relevance of this typical morphological sign in the examination of possible electrocution fatalities is therefore emphasised.