Determination of questionable suicide as a homicide by studies of criminal stains

In a woman found dead with cuts on both arms in a domestic sauna plastered with blood were assumed next to a bleed to death. The question self-infliction or by a third party of arm injuries could not be decided. By investigation of blood traces only could be clarified the cause of death. The husband had strangled his wife and inflicted several cuts on both arms with a razor blade to simulate suicide. Afterwards, he also inflicted several cuts on himself with a razor blade with the intention of suicide. He survived these injuries.     

Simulation of an attack by self-mutilating cuts and stab wounds

Self-inflicted cut or stab wounds may be used by the injured to make credible a feigned assault. In such cases the alleged traces of the crime are found on the body and the clothing of the informant. Occasionally the very pattern of the injuries points to self-infliction. For example the following findings may be indicative of self-infliction: a greater number of very superficial wounds, wounds parallel or grouped, mostly located on the left side of the body (in right-handers) or symmetry in arrangement, intact clothing or lack of correspondence between wounds and damage of clothing, absence of typical defence and protection injuries. In the light of 4 cases observed from the material at hand, special features of the lesion appearance are shown and possible motives for the deed discussed.     

Secondary combined suicide viewed by the wife]

A 47-year-old man was found dead at the bottom of a wall outward the door of the cellar of his house. Preliminary physical examination at the scene of the death revealed a laceration of the scalp, an incised wound in front of the neck and several stab wounds in the left chest penetrating through the clothing. Questioned by the police his wife told that her husband who suffered from severe depression had inflicted the incised and the stab wounds himself, had made an unsuccessful attempt at self-strangulation and had finally jumped down from the wall beside the stairs declining to the cellar of their house. As the circumstances of the scenario were suspicious and as the pattern of injuries arose doubts concerning self-infliction homicide was taken into consideration as well. Autopsy showed additional hesitation marks adjacent to the left end of the incised wound in front of the neck. The stab wounds of the chest were restricted to the region of the heart and displayed only minimal penetration of the chest-wall, findings characteristic of self-infliction. As a consequence the manner of death could be determined as prolonged suicide, and exact reconstruction was possible with the help of the wife's testimony.     

Survived stab to the heart in a schizophrenic man

Schizophrenia is associated with a significant risk of suicide. According to recent research, 10-15 % of all schizophrenic patients die by suicide. It is not uncommon that the victims show sharp force injuries, so that the forensic pathologist first has to differentiate between self-infliction and involvement of another person. The authors' case report presents a 68-year-old schizophrenic patient who committed suicide by jumping out of a window of his apartment located on the second floor after inflicting multiple stab wounds to his thoracic region. At autopsy, an older stab wound to the apex of the heart was detected. In the criminal investigation, a suicide attempt made 13 days before could be ascertained. As the patient did not want to be taken to a hospital at that time, the injury had never been examined or documented. Since there was no evidence suggesting homicide, the older stab to the heart was interpreted as a tentative injury.     

Empirical criteria for the determination of suicide manner of death

A 16-item instrument was constructed as a tool to assist medicolegal official in their investigations and certifications of suicidal deaths. The Empirical Criteria for the Determination of Suicide (ECDS)--derived from a combined set of the 22 criterion items of the Operational Criteria for the Determination of Suicide (OCDS) and 33 other items obtained from experts and the professional literature--was constructed and validated by using 126 suicide and accident cases obtained from 70 medical examiner participants. Analysis of the cases confirmed that suicide is a manner of death in which there is evidence of both self-infliction and intention to die. The 16 items retained in the ECDS discriminated suicides from accidents best in relation to self-infliction and intention. In analysis of its concurrent validity, the ECDS instrument predicted 100% of the suicides and 83% of the accidents, thus correctly identifying 92% of all cases.     

Death certification of "suicide by cop"

Death certification of "suicide by cop" is controversial among some medical examiners and coroners. We present five such deaths that were certified as suicides and discuss the medico-legal issues involved with these certifications. To certify such a death as a suicide, certain criteria should be met. Suicide by cop is a circumstance that involves competing intentional acts that may result in dichotomous determinations of the manner of death. Despite the absence of direct self-infliction, there is overwhelming evidence that these five individuals intended to end their own lives. Their use of an unusual method to accomplish this goal may inappropriately result in a reflexive certification of homicide. All of the decedents possessed weapons or a facsimile of a weapon. We present five instances of suicide by cop and contend that these types of deaths are best certified as suicides.     

An unusual case of thermal injuries with a hot glue gun: Deliberate self-harm or maltreatment?

Assessing injuries in forensic medicine casework, examiners are often confronted with the question of self-infliction versus third parties' influence, respectively, deliberate self-harm versus maltreatment. We report the case of a 40-year-old male who presented with numerous partially healed thermal injuries of different age. These burns were shaped like capital letters and little circles, which were arranged in lines in a regular form. The lesions were found on the whole body with exclusion of face, genitals, hands and feet. Furthermore, four bitemarks at the right shoulder were noted. Investigations revealed that the man had been abused by his 25-year-old wife (presumably a borderline personality disorder patient) for at least 1 year. In addition to another series of abuses, the woman may have inflicted the shaped burns with a hot glue gun as punishment for breaking certain "rules" she had established. When assessing injuries of patients in forensic medicine, several considerations regarding etiology have to be taken into account. In principle, the victim's testimony, the anamnesis, the police investigation results and the findings from the forensic physical examination have to be balanced against each other. The injury pattern in the present case showed contradictory single characteristics both of deliberate self-harm and of maltreatment. After forensic analysis, it was assessed as injuries inflicted by an assistant with the patient's consent.     

Computer aided shot reconstructions by means of individualized animated three-dimensional victim models

In cases of lethal firearm injuries with indefinite indications concerning self-versus third-party infliction a computer enhanced reconstruction with the aim of an anatomical feasibility study can provide significant clues concerning the course of the traumatic event.To this end an exact three-dimensional geometrical model of the victim including all relevant anatomical data as well as the careful documentation of the injuries and a three-dimensional model of the characteristic outlines of the weapon true to scale is generated with the help of an animation program (POSER Version 4, Meta Creation, Egisys AG).With this animated digital three-dimensional model of the victim and the weapon a series of simulation sequences is created by variation of the body positions and the grasp of the weapon. Anatomically impossible positions in view of the physical characteristics of the victim and the site and direction of the bullet path are automatically excluded from the reconstruction. An exact match of the simulation sequence and the real injuries is a statement for a possible self-infliction of the gunshot wound.     

Differentiation between self-inflicted and homicidal stab wounds to the neck

39 autopsy cases with throat incision examined in the Bonn Institute of Legal Medicine in the years 1990 through 1998 were evaluated with respect to the query whether the morphological criteria generally established for the differentiation between homicide and suicide are also suitable for the assessment in this special localization. Integrative consideration of localization, direction of incision, hesitative resp. tentative injuries, defence injuries, concomitant injuries and capability to act allowed for a discrimination on grounds of legal medical findings in 84 per cent of the cases.     

Fatal descent from height in New York City

All deaths due to descent from height that underwent autopsy at the Manhattan Office of Chief Medical Examiner of New York City over a two year period (1997-1999) were reviewed. The scene and autopsy findings, psychiatric history, and toxicology results were examined. There were 120 deaths: 77 suicides, 36 accidents, 5 undetermined, and 2 homicides. Psychiatric illness was reported in 86% of suicides. The toxicological detection of psychiatric medications supports the high percentage of psychiatric disease in the suicide group. In the accidental group, the detection of ethanol and illicit drugs was higher (36%) than expected from the case investigation and similar to the suicide group (29%). Accidental falls by women made up fewer than 3% of all manners. Due to the variation in the extent of injuries, it is unwise to attempt to conclude how high a person descended based on the autopsy findings. Descents into water commonly have minimal findings on external examination with marked internal injuries. The methods of investigation and criteria for death certification using the study results are discussed.     

How extensive can injury of the larynx in self-choking be?]

Is it possible to distinguish between suicidal and homicidal strangulation by the extent of the injuries of the larynx if the results of the police investigations are uncertain? Therefore evaluation of the German publications (115 reported cases of suicidal strangulation) and our own cases (17 cases). Hereafter more intensive injuries of the neck are extremely rare in cases of self-strangulation. Casuistic: Body of a 40 years old woman with signs of strangulation. The husband declared his wife strangulated herself in the bathtub with the belt of a bathrobe. Autopsy: Typical findings of drowning, intensive injuries of the neck tissues and the larynx. Kind and extent of the findings are speaking well for an assault mainly by manual strangulation. Undepending of the medical findings the police investigations are almost excluding a suicide. Condemnation of the husband.     

Self-mutilation in men--injury pattern and motivation

6 cases of self-inflicted injuries in male individuals are reported. The age of the affected men was between 15 and 46 years whereas the younger age predominated. Alleged incidents were robberies in 3 cases, rape in one case, violation in custody in one case and an assault originating in personal motives in one case. In 4 cases, the typical injury pattern of self-infliction was present showing parallel course and superficiality of the wounds in areas accessable by the persons's own hands. In 2 cases, atypical injuries (i.e. deep cuts and massive signs of strangulation respectively) were found. However, in most cases, the underlying motive was to gain affection. An autoerotic accident was tried to be disguised in one case. Profit was the leading motive in another case.     

Jumping Together: A Fatal Suicide Pact

In suicide pact, two or more victims mutually agree and execute to end their lives together by predetermined method, preferably by hanging, drowning, gunshot, or poisoning. The victims are usually spouses, lovers, or friends, and the reasons behind such steps are various. In this reported suicide pact, husband–wife duo jumped from the terrace of a 12‐meter‐high building with their wrist bound to each other. Although they jumped together, the injury patterns were completely different. The man landed on head sustaining mainly craniocerebral injuries, and the wife landed on feet sustaining long bone injuries. They left a suicide note pointing out sudden demise of their only child as the reason for the suicide, and it was signed by both of them. Jumping from a height in suicide pact has not been reported in the scientific literature yet.     

Suicide in children and adolescents: a 10-year retrospective review

Suicide is second only to accidents as the most common cause of death for children and adolescents age 10 to 19 in Canada. All of the pediatric cases that were referred to the Hamilton Regional Forensic Pathology Unit from 1993 to 2002 were reviewed. For the purpose of this study, pediatric deaths were defined as deaths in the age group of 1 day up to and including 19 years of age. Specific criteria for suicide were applied to each case, independent of the manner of death issued by the coroner. The criteria were 3-fold. First, homicide had to be ruled out by the police investigation and autopsy findings. Second, the method had to be consistent with self-infliction. Finally, there had to be some evidence of suicidal intent. Questionable cases were discussed among the authors, and if reasonable intent could not be established, then the case was excluded. The autopsy and police reports were examined in detail regarding age, sex, location and method of suicide, presence of suicide notes, and any contributing psychologic factors or stressors. Of the 501 pediatric autopsies performed during the 10-year period, 31 (6%) met the criteria of suicide. The majority of cases (87%) were in older adolescents (age 15 to 19), and the male to female ratio was 2.4:1. Psychologic factors were identified in some of the cases, including depressed mood (77%), suicidal ideation (45%), previous suicide attempts (23%), and drug or alcohol problems (19%). Most of the suicides (61%) occurred in the victim's home, and 12 (39%) cases left a suicide note. In 9 cases (29%), alcohol or street drugs were detected postmortem, though in 8 cases toxicology was not performed. Hanging (48%) was the most common method of suicide, followed by firearms (13%), poisoning (10%), drowning (10%), and blunt force vehicular trauma (10%). Almost 60% of the male suicides were by hanging. No specific trend was identified in the 9 female suicides. These results were compared with similar studies within Canada and other countries. Overall, the method of suicide is dictated by what is convenient and readily available, though the acceptance of various suicide methods can change over time. Suicide prevention efforts should be tailored to address local trends.     

Suspected suicide and suicide attempt with mysterious concomitant circumstances

Two cases of suicide and attempted suicide, respectively, are presented. A 15-year old boy suffering from diabetes died of hyperglycemia after continuous drinking of large amounts of sugared tea. He concealed his disease from the teachers as well as from the doctor. A 52-year old woman was found with multiple blunt force injuries and stab wounds. The suspicion of homicide attempt could be clarified, as all of the injuries were self-inflicted.     

Cervical findings and petechial hemorrhages in falls from high positions

Cases of combined suicide are infrequent findings, especially cases in which each method can be lethal. In interpretation of cases with a multitude of serious injuries it might be impossible to discover minor injuries which had occurred in the course of a preceding confrontation, because they may be masked by the general traumatization. In two cases of suicidal fall from a height neck injuries and petechial bleedings were found. The first case (woman 53 years) was a combination suicide (strangulation by ligature, deep incisions into her wrists, jump out of the window). The intensive petechial bleedings in the face could be explained as a result of ligature strangulation and the fracture of a lower thyroid horn as an indirect fracture resulting of the head traumatization. In the second case (girl, 14 years) petechial bleedings in the face were found. Furthermore the victim had marks on her neck-skin, consisting of well-lined bleedings and scratches, presenting a clear pattern, which could be related to a necklace. An explanation of these injuries as a result of a direct impact could not be given. Something must have happened prior the fall. Informations concerning the last hours before her suicide could not be obtained but a strangulation-attempt (by herself? by others?) must be ascertained. The histological investigation of the skin of this region arised a negative vital reaction, therefore a very short interval between that event and the death was assumed.     

Gunshot reconstructions based on individually parametrical 3-dimensional victim models]

In cases of lethal firearm injuries computer enhanced anatomical feasibility studies can provide unambiguous clues concerning self-versus extraneous infliction. To this end individualized digital 3-dimensional geometrical models of the victim and the weapon are generated true to scale with the help of the CAD software (POSER Version 4, egi.sys AG). All anatomical data relevant to the motion apparatus and the range of movement as well as the injuries of the individual victim are carefully documented and serve as input parameters for the digital geometrical model. The bullet path is visualized as a cylinder between entrance and exit wound. A series of simulation sequences then can be carried out by the variation of anatomically possible shot positions and the virtual grasp of the weapon. An exact alignment of the firearm's barrel and the bullet path is a reliable statement for the feasibility of self-infliction. In addition to circumstantial evidence the digital reconstruction of the firearm shot admits of unambiguous conclusions about the course of the traumatic event.     

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."     

Complex Suicide by Self‐stabbing and Drowning: A Case Report and a Review of Literature

Sharp force injuries and drowning are methods exceptionally combined in complex suicides. We report a challenging case of complex suicide by self‐stabbing and drowning that illustrates the difficulty in discriminating between homicide and suicide in such circumstances of death. The corpse of a young man was found submerged in a river, stabbed nine times with two wounds that had penetrated the thorax and had caused lung injuries and a hemopneumothorax. The postmortem and histological examinations were consistent with a death caused by drowning, but the manner of death still remained undetermined. Police investigation finally concluded to a suicide, although no suicide note had been left and the victim had no underlying diagnosed mental disorder. The parameters that may help distinguish suicide from homicide at the autopsy should be interpreted in light of a thorough forensic investigation to determine the exact manner of death in such a case.