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Local case report delves into unplanned, complex suicide 

a year ago

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BY Ruwan Laknath Jayakody When taking measures to prevent death by suicide, there is a need to look into cases of unplanned, complex suicides where more than one method of suicide is utilised, forensic academics noted. This observation was made in “A case report on a complex suicide of a drug addict” which was authored by H.K.R. Sanjeewa (Postgraduate Trainee) and Prof. M. Vidanapathirana (attached to the University of Sri Jayewardenepura Medical Sciences Faculty’s Forensic Medicine Department) and was published in the Medico-Legal Journal of Sri Lanka 5 (1) in December 2017. Death by suicide, as Sanjeewa and Vidanapathirana noted, are divided into simple and complex suicides with the latter being explained by S. Demirci, K.H. Dogan, Z. Erkol, and I. Deniz in “A series of complex suicides” as a suicide where more than one method of suicide is applied. It is further classified by Sanjeewa and Vidanapathirana as planned (primary) and unplanned (secondary) complex suicides. In the case of the former, two or more methods are employed at the same time, per M. Bohnert’s “Complex suicides” in order to ensure death even if one method were to fail.  According to Bohnert, in such situations, generally the common combination of methods involve drowning, the ingestion of medicinal drugs, hanging, the use of firearms, and jumping from a height. In the case of unplanned, complex suicides, several other methods of suicide are attempted, as pointed out by S. Kucerova, P. Hejna, L. Zatopkova, and L. Straka’s “Primary and secondary complex suicide”, upon the failure of the chosen first method.  Sanjeewa and Vidanapathirana elaborated that in such instances, injuries inflicted by sharp force, in particular, cutting the wrists, are oft found as the first act while in other cases, the infliction of cut wounds to the wrists changes to the infliction of stab wounds on the area of the chest. According to Kucerova et al., other frequently used methods following the failure of the first method involve hanging and jumping from a height. Hence, Sanjeewa and Vidanapathirana discussed a local case of a death involving two methods of suicide. Case report The body of a 20-year-old, unmarried, male, drug addict (per the Police) was recovered from a river. According to the deceased’s mother, he had cut his neck at home (a blood stained table knife was found in his room) and then jumped into the river. There were no features of a struggle at the scenes. The body was recovered 24 hours after the initial incident. The victim had no previous history of suicidal attempts. The autopsy examination revealed that the deceased was a person of average build. His dominant hand was the right and there were several superficial, multiple, parallel scars on the front aspect of the left forearm.  There were however no macro or microscopic evidence such as venipuncture sites (the process of obtaining intravenous access where a hollow needle is inserted through the skin and into a superficial vein), lung fibrosis (the development of fibrous connective tissue as a reparative response to injury or damage), and foreign body granulomas (a small area of inflammation). There were four cut injuries on the front aspect of the neck which were superficial and parallel, and were not associated with any deep injuries on structures such as the strap muscles (a group of four pairs of muscles in the frontal part of the neck), airways or neck vessels.  Fine continuous froth was found in the nose and mouth. The lungs were hyper inflated. There were no defence injuries. According to the histopathological (the diagnosis and study of diseases of the tissues) studies, there were foreign bodies beyond the secondary bronchi (the first subdivision of the main/primary bronchi, the latter being the two large tubes that carry air from the windpipe to the lungs) and the other organs did not show any remarkable findings. The toxicological analyses of blood and bile were negative for common poisons, alcohol, narcotics, and drugs. The cause of death was given as drowning. Explaining the post-mortem findings, Sanjeewa and Vidanapathirana added that injuries caused by propellers, animal predators, or water monitors can mimic cut throat injuries in bodies recovered from the water; However, in post-mortem animal bites, in addition to the teeth injuries, there are associated claw marks which are haphazardly placed, and in this case, the absence of such teeth or claw marks excluded possible post-mortem animal bites.  Furthermore, even though propellers could cause multiple, parallel cuts to the body, the presence of such injuries at an elective site of suicide favoured ante-mortem cut throat injuries and should have been received before entering into the water, a fact which was, Sanjeewa and Vidanapathirana added, also confirmed through eye witness evidence. Cut throat injuries, Vidanapathirana and J.C. Samaraweera explained in “Homicidal cut throat: The forensic perspective”, are found in different circumstances, namely, accidental, suicidal, and homicidal. Since distinguishing this aspect of the cut throat injuries is challenging for forensic pathologists evaluating such neck injuries, T. Ohshima and T. Kondo emphasised in “Eight cases of suicide by self cutting or stabbing: Consideration from medico-legal viewpoints of differentiation between suicide and homicide” that the scene investigation findings, the deceased’s medical history, the autopsy, and toxicological findings must be considered with a sceptical approach before establishing the manner of death.  Per Vidanapathirana and Samarajeewa, homicidal cut throats are commonly associated with defence or bizarre type of injuries and such were not found in the instant case, whereas suicidal cut injuries are usually multiple, parallel, and superficial and found at elective sites such as the neck, as was the case in the deceased. While suicidal knife injuries to the neck can be cuts or stabs, per B. Solarino, C.T. Buschmann, and M. Tsokos’s “Suicidal cut throat and stab fatalities: Three case reports”, in this case, there were only cut injuries.  Explaining further, Vidanapathirana and Samaraweera pointed out that suicidal cut throats are accompanied by tentative or hesitant cuts or stabs, which are also multiple, almost parallel, and superficial. W.U. Spitz’s “Sharp force injury” further noted hesitation cuts which are usually found on the wrists, the front of the neck, and less commonly in the elbow or on the ankles. In this case, of the four cut throat injuries, the lowest and most superficial cut could be, as per Sanjeewa and Vidanapathirana’s analysis, considered a hesitant cut.  Moreover, Vidanapathirana and Samaraweera elaborated that in homicidal cut throat injuries, the scene is usually disturbed while the weapon is taken away by the perpetrator, whereas in suicidal cut throat injuries, the scene is undisturbed and the causative weapon is usually found at the scene as was the case in the present matter. For Sanjeewa and Vidanapathirana, death by suicide is more commonly associated with psychiatric illness, substance abuse (in this case, the deceased was a drug addict), or a history of previous suicidal attempts (in this case, while there was no previous suicidal attempt, there were scars of several previous self-inflicted injuries). Hence, Sanjeewa and Vidanapathirana noted the circumstance of the cut throat as suicide. That said, since the neck injuries did not penetrate deep structures and there were no major vessel or airway damage, there was also no corresponding autopsy evidence of the mechanisms of death of cut throat injuries such as haemorrhagic (bleeding) shock, air embolism (a blocked artery caused by a foreign body such as an air bubble), or the aspiration of blood.  Moving on to the fact of the body being recovered from the water, Sanjeewa and Vidanapathirana explained that when a body is recovered from the water, in order to diagnose drowning as the cause of death, there is a need to exclude fatal injuries or natural diseases that occur before or after entering the water while the toxicology screening too should also be negative. In this regard, there was no macroscopic or microscopic evidence of any significant natural pathology. Moreover, the diatom (a type of plankton called phytoplankton) test was negative.  “However, the fine froth with inflated lungs and microscopic evidence of foreign bodies beyond the secondary bronchi indicated that emphysema (the gradual damage of lung tissue, specifically the destruction of the tiny air sacs) aquosum (hyper expanded and waterlogged lungs) is a mechanism of death in this case. Foreign matter beyond the secondary bronchi in a non-putrefied body may also indicate that the person was alive when he entered the water,” the duo added.  Therefore, the manner of this particular immersion was ascertained as suicide. In conclusion, Sanjeewa and Vidanapathirana emphasised that when two potential modes of death are present (cut throat and jumping into a river), the real cause of death must be ascertained. In this case, they noted, since there was no evidence of any mechanisms of death due to cut throat injuries (inflicted prior to entering the water), and the only available mechanism of death was emphysema aquosum due to immersion, the cause of death was ascertained as drowning. Due to the use of two suicide methods, namely cut throat and jumping into a river, this is a complex suicide, but since the initial cut throat injuries had failed to cause death and subsequently the victim decided to jump into a river, this has the element of being unplanned, thus making this an unplanned, complex suicide. If you’re affected by the above content or if you/someone you know may be dealing with a similar situation, the following institutions would assist you: The National Institute of Mental Health: 1926 Sri Lanka Sumithrayo: 0112 682 535 Shanthi Maargam: 0717 639 898 Courage Compassion Commitment (CCC) Foundation: 1333