Planned complex suicide. Report of two autopsy cases of suicidal shot injury and subsequent self-immolation

Two cases of planned complex suicide are presented. In both cases, the suicidal persons shot themselves after making sure that in the sequel their bodies would be burnt. In the first case, a 65-year-old man had shot himself in the mouth and consequently fell into a fire he had lighted before. In the second case, a 43-year-old man set fire to his flat and shot himself directly afterwards. On the basis of the reported cases, a short literature review on planned complex suicides is given.     

Asphyxial deaths: a retrospective study and review of the literature

An increasing death rate as a result of violence constitutes a large group in medicolegal autopsies. Specially, deaths due to asphyxia are one of the most important causes in violence deaths.During the 21-year period from January 1984 to October 2004, there were 134 asphyxial deaths autopsied by the Department of Forensic Medicine, Trakya University, Edirne, Turkey. Asphyxial deaths comprise 15.7% of all forensic autopsies; 20.8% of the cases are aged between 30 and 39 years, and the average age was 41.9 years. Males constitute 79.8% of all the cases.The most frequent method of asphyxiation death is hanging (56 cases, 41.8%), followed by drowning (30.5%) and carbon monoxide poisoning (8.2%). More violent methods, such as ligature or manual strangulations, constitute 2.9% and 2.3% of all asphyxial deaths, respectively. Although it was varying according to the methods of asphyxiation, suicide was found to be the manner of death in the majority of the cases.     

Autoerotic deaths: a 25-year retrospective epidemiological study

It is written in almost all articles on autoerotic deaths that these fatalities account for about 500 to 1000 deaths per year in the United States and Canada. However, contrary to the general belief, this incidence rate was not obtained through a study, but it is an estimation based on 30-year unpublished data from Canada and England. In the present retrospective study from 1985 to 2009, 38 cases of autoerotic deaths were identified in the province of Alberta (Canada). This number corresponds to an incidence of 0.56 autoerotic deaths per million inhabitants per year. The vast majority of these deaths are related to typical, predominantly asphyxial methods, such as hanging. The bodies were most commonly found in basements, bedrooms, and bathrooms. There is no clear evidence of a preferential time of day for these deaths, but there appear to be slightly more autoerotic deaths during summer. The incidence of autoerotic deaths is higher in big cities compared with rural areas. The previously published estimate of 500 to 1000 'autoerotic deaths per year should not be used for Canada. An incidence of 0.2 to 0.5 cases per million inhabitants per year is a better estimate of the incidence of autoerotic deaths. The incidence in United States should be reassessed using epidemiological studies.     

Pediatric toxicologic deaths: a 10-year retrospective study

A 10-year retrospective study of pediatric toxicologic deaths was performed at the Medical University of South Carolina (Charleston, SC) from January 1989 to December 1998. During this time, 709 pediatric forensic autopsies were performed on children younger than 18 years of age. Eleven deaths were determined to be secondary to toxic exposures (excluding carbon monoxide poisonings secondary to fires). The remaining deaths were reviewed for the presence of alcohol or illicit drugs. The 11 toxicologic deaths were analyzed for age, sex, race, type of toxic exposure, cause and manner of death, location of incident, witness, and, in the younger age group, the primary caregiver at the time of exposure. The deaths had a bimodal age distribution (6 deaths in victims ages 15 to 17 and 5 deaths in victims ages 4 or younger), involving a wide range of toxins. The teenage group was composed of five males and one female, all white. The preschool group had three females and three males, all black. The manner of death ranged from accidental to suicidal to homicidal. In addition, in eight neonatal and fetal deaths, the victims tested positive for maternal cocaine use, and five of these victims tested positive for cocaine or benzoylecgonine. However, the cause of death was not stated to be cocaine in any of these neonatal and fetal cases.     

Elderly suicide: a 10-year retrospective study

The suicide rate in the 65-year and older age group has been increasing since 1980. The elderly attempt suicide less often than younger people but are successful more often. The authors retrospectively reviewed all cases referred to the Forensic Pathology Section of the Medical Examiners' Office at the Medical University of South Carolina (Charleston, SC) from January 1988 through December 1997. The cases of suicide in victims 65 years and older totaled 78, accounting for 11.5% of all suicides reviewed. Of these 78 cases, 41% were autopsied and 59% were externally examined. All of the cases were initially analyzed as to age, race, sex, and method of suicide. Files also were reviewed to determine time of year of the suicide, toxicology results, psychiatric history, social history, medical history, and whether a suicide note was left. The ages of these suicide victims ranged from 65 to 94 years; men comprised 85% of the victims, and whites, 94%. The male-to-female and white-to-black ratios were 6:1 and 15: 1, respectively. The average age of the victim was 73 years. Gunshot wound was the most common method of suicide, accounting for 80.7% of the cases. Other methods included overdose (6.4%), hanging (3.8%), fall from height (2.6%), incised wounds (2.6%), drowning (2.6%), and carbon monoxide poisoning (1.3%).     

Suicide by self-immolation in Durban,South Africa: a five-year retrospective review

Self-immolation is an uncommon method of suicide, and its occurrence in South Africa is thus far unknown. This study aimed to determine the prevalence of self-immolation deaths and to establish a profile of these cases and the circumstances under which this condition occurs. A 5-year (1996-2000) retrospective review at a mortuary in Durban, South Africa, was conducted. Data were obtained from the Department of Forensic Medicine, the Medical Research Council's National Injury Mortality Surveillance System, and police and hospital records. During the study period, there were 12339 nonnatural deaths, of which 696 (5.6%) were suicides. Self-immolation accounted for 69 (0.6%) of all nonnatural deaths and 69 (9.9%) of all suicides. The subjects had a mean age of 31.2 years and were predominantly female (76.8%) and black (81.2%). The mean burn surface area was 63.3%, and the mean injury severity score was 36.9. Accelerant use was documented in 53 (76.8%) of cases, and paraffin was preferred. All cases occurred indoors. The proportion of suicides due to self-immolation in our study is excessive when compared with international studies that report figures between 0.9% and 2.2% of suicides. Additional studies are necessary to further elucidate the reasons for this discrepancy.     

Drugs and alcohol in hypothermia and hyperthermia related deaths: a retrospective study

Hypothermia and hyperthermia related cases recorded for the period 1973 to 1984 were collected from the files of the Department of Forensic Medicine, University of Oulu, and the necropsy protocols including toxicological results were analyzed. The fact that similar alcohol concentrations were found in both types of fatalities points to the poikilothermic effect of alcohol in humans, as found in animal studies. Both types of deaths seem to be associated with the alcohol elimination phase. Antidepressants and neuroleptics were most often found in the hypothermia cases, but benzodiazepines were also quite frequently present. In spite of the diminished use of barbiturates, these still appear in hypothermia fatalities. Certain other drugs that affect thermoregulation were also noted in solitary cases. Extended toxicological analysis was seldom made in the cases of hyperthermia deaths, and no firm conclusions on the poikilothermic effect of psychotropic drugs could be reached, for example. Therapeutic drug concentrations did not alone predispose the subjects to hypothermia, but appeared in connection with alcohol consumption or chronic diseases.     

Acute ethanol poisoning: a two-year study of deaths in North Carolina

A 24-month study of fatalities in North Carolina with high blood ethanol levels (300 mg/100 ml or over) revealed 502 cases with either acute alcoholism or the effects of this range of blood ethanol concentration having caused or contributed to death. This investigation reassessed the criteria for ethanol poisoning, including its cause and manner of death, and revealed recurrent patterns common to this syndrome. This inquiry also contrasted the frequency of ethanol poisoning in different areas of the country.     

Pregnancy-associated deaths: a 15-year retrospective study and overall review of maternal pathophysiology

Pregnancy-related death is defined by the International Classification of Diseases, Tenth Revision (ICD-10) as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death. In the year 2000, a collaborative effort involving World Health Organization (WHO), UNICEF, and UNFPA estimated 660 maternal deaths in the United States. This averages 11 maternal deaths per 100,000 live births reported. Many pregnancy-associated deaths are not easily identified as such since the presence of a recent or current pregnancy may not be listed on the death certificate. Thus, the WHO estimates that in the United States, the maternal mortality is approximately 17/100,000 pregnancies. This is significantly higher than the goal set by the US Department of Health and Human Services in Healthy People 2010, which sets the target for maternal mortality at less than 3.3/100,000 live births. The most common causes of maternal death vary somewhat from region to region in the United States. They include pulmonary thromboembolism, amniotic fluid embolism, primary postpartum uterine hemorrhage, infection, and complications of hypertension including preeclampsia and eclampsia. Pulmonary disease, complications of anesthesia, and cardiomyopathy also are significant contributors to maternal mortality in some populations. The death of a pregnant or recently pregnant individual poses a wide scope of challenges to the forensic pathologist and investigator. The pathologist must have a broad knowledge of the physiologic and biochemical changes that occur during pregnancy, as well as the clinical and pathological manifestation of these changes. Conditions that may be "benign" in the nonpregnant individual may be lethal in the puerperal period. In addition, it should be kept in mind that deaths during pregnancy may be due to unnatural causes. Accident, homicide, and suicide must be ruled out in each case. The authors reviewed all forensic cases referred for autopsy to the Forensic Section of the Medical University of South Carolina from January 1989 through December 2003. All decedents listed as pregnant or postpartum were analyzed as to maternal age, race, past medical history, previous pregnancies and outcome, prenatal care, gestational age, fetal or neonatal outcome, location of delivery, placental findings, maternal autopsy findings, toxicology, cause of death, manner of death, and fetal or neonatal autopsy findings. The authors present this retrospective study to better determine the factors leading to maternal demise and discuss the autopsy/ancillary techniques useful in determining the cause of death in this challenging area.     

Asphyxial deaths and petechiae: a review

Conjunctival and facial petechiae, although nonspecific findings, are considered hallmarks of asphyxial deaths. Consensus in the literature suggests that their pathogenesis is related to the combined effects of increased cephalic venous pressure and hypoxic damage to endothelial cells. Despite the common knowledge that they are neither predictable findings in all asphyxial deaths nor rare in natural, nonasphyxial deaths, the belief persists that petechiae are corroborative evidence of asphyxia. We suggest that a clear, physiologically based understanding of the pathogenesis of petechiae of the head is critical for their appropriate interpretation. We present a review of the literature and the basis of our conclusion that conjunctival and facial petechiae are the product of purely mechanical vascular phenomena, unrelated to asphyxia or hypoxia.     

Factors in prison suicide: one year study in Texas.

The goal of the study was to examine psychopathology and stressors suffered by suicide victims, and to describe the characteristics of the suicides in the Texas Department of Criminal Justice between June of 1996 to June of 1997. Data on 25 completed suicides were collected from the records department. Results: The authors identified 60% of the suicide victims with a history of psychiatric disorders. Seventy-six percent had been diagnosed with psychiatric disorders while incarcerated. The most frequent psychiatric disorders were mood disorders (64%), psychotic disorders (44%), personality disorders (56%), and comorbidity with a history of presentencing alcohol and drug abuse was common. Most of the victims experienced chronic and/or acute stressors of acute trauma, disrupted relationship, sentence hearing, and/or medical condition. We concluded that important factors associated with increased risk of prison suicide include psychiatric disorders, comorbid substance abuse, a history of suicide attempt, and chronic and/or acute stressors.     

The descriptive epidemiology of unnatural deaths in Oregon's state institutions: a 25-year (1963-1987) study. I. A preliminary analysis of recent incidence rates of suicide in mental and correctional facilities

This paper presents for the first time the annual suicide incidence rates of residents from four Oregon state institutions for a 5-year (1983-1987) period of time. The suicide rate for inmate-patients of the Forensic Psychiatric Program (for the care and treatment of individuals who have been found guilty of serious crime and to be mentally ill) is 820/100,000. This represents a suicide rate 51 times higher than the rate for Marion County or the state of Oregon. This is also one of the highest annual suicide rates ever reported. The suicide rate for patients of the Oregon State Hospital is 289/100,000, which is similar to other reported suicide rates in hospitalized mentally ill populations. This rate is approximately 18 times higher than the rate for Marion County or the state of Oregon. The suicide rate for inmates of Oregon's four correctional institutions is approximately 29/100,000, which is similar to other reported rates for prisoners. This rate is approximately 1.8 times higher than the rate for Marion County or the state of Oregon. The suicide rate for residents of the Fairview Training Center (for care of the mentally retarded and developmentally disabled) is zero.     

Inhalant deaths in South Australia: a 20-year retrospective autopsy study

A 20-year retrospective study of inhalant deaths in South Australia, autopsied at Forensic Science SA, was undertaken from January 1983 to December 2002. Thirty-nine cases were identified from an autopsy pool of 18,880 cases, with a male to female ratio of 12:1. Sixty-four percent of the victims (N = 25) died during voluntary inhalation of volatile substances and 28% (N = 11) committed suicide utilizing a volatile substance or gas. The remaining 3 cases involved a workplace accident (N = 1) and 2 cases of autoerotic death where inhalants were being used to augment solitary sexual activity. The mean age of the 28 victims of accidental inhalant death of 21 years (range, 13-45 years) was considerably less than that of the 11 suicide victims of 31.5 years (range, 17-48 years). No homicides were found. Approximately one quarter of the victims were Aboriginal (N = 11), 10 of whom had died as a result of gasoline inhalation ("petrol sniffing"). Other common substances of abuse were aliphatic hydrocarbons such as butane. The study has shown that those most at risk for accidental or suicidal inhalant deaths were young males, with 92% of victims overall being male, and with 77% of victims being under 31 years of age. Gasoline inhalation remains a significant problem in Aboriginal communities in South Australia.     

The murder-suicide. A study of the postagressional suicide

The authors studied a series of 18 cases of homicide followed by suicide or attempted suicide by the aggressor, analyzing: 1) the frequency of such acts; 2) the age and sex of the aggressors; 3) the means or arms used for the murder and suicide; 4) the period of time between the two events; and 5) the motives for the homicides and the relationship between the victims and their aggressors.     

Blood alcohol concentrations of sudden unexpected deaths and non natural deaths.

This study reports on the relationships between the blood alcohol concentration (BAC) and the cause of death - which is of course common knowledge for forensic scientists! Our special aim was to gain unselected data for generalizing conclusions. The blood of 2465 consecutive cases (86% of all 2852 sudden unexpected and unnatural fatalities investigated at the Institute for Legal Medicine in Hamburg during the year 1989) was analysed. The BAC was evaluated according to sex, age, cause of death and place of death. In natural causes of death there were 80% cases under 0.05% BAC. Endocrine and digestive system diseases in particular were associated with positive BAC values. In unnatural death cases the BAC under 0.05% was found in 64% of the suicides, 62% of the accidents, 54% of the homicides and 51% of the drug intoxications. The drowning cases showed higher BAC's than traffic accidents. In suicides middle aged males had high BAC's.