• Less lethal suicide attempts/suicidal gestures can still have serious consequences, including injury/accidental death

Para-suicidal attempts – a less lethal suicide attempt or a suicidal gesture, which constitutes a deliberate act of self-harm that is not intended to result in death but which can still have serious consequences, including injury or even accidental death – often serve as a way to communicate distress rather than a genuine attempt at suicide.

These observations citing J.E. Jones, B.P. Hermann, J.J. Barry, F.G. Gilliam, A.M. Kanner and K.J. Meador's ‘Rates and risk factors for suicide, suicidal ideation, and suicide attempts in chronic epilepsy’, and S.S. Welch's ‘A review of the literature on the epidemiology of para-suicide in the general population’ were made in a case report on ‘An unintended asphyxiation of a para-suicide: Forensic challenges in determining the circumstances’ which was authored by W.M.T. Lowe and S.R. Hulathduwa (both attached to the Sri Jayewardenepura University's Medical Sciences Faculty's Forensic Medicine Department), and P.B. Dassanayake (attached to the Kalubowila Colombo South Teaching Hospital's Office of the Judicial Medical Officer [JMO]), and published in the Sri Lanka Journal of Forensic Medicine, Science and Law's 16th Volume's (Special Issue), last month (May).

Hanging is a common method of suicide in Sri Lanka. The differentiation of the circumstances of such para-suicidal attempts leading to death will be a major concern for the JMO.

Case history 

A 41-year-old male manual labourer with a documented history of chronic alcohol abuse and recurrent domestic violence incidents, including recent legal charges for spousal battery, presented with fatal suicidal hanging. He had multiple prior suicide attempts by hanging, according to the collateral history from the family and community members. 

On the day of the incident, he had locked himself up inside the house following an altercation with his wife. Upon forced entry by his family members 30 minutes later, they discovered the deceased partially sitting in front of their cupboard, suspended with a saline tube around the neck and connected to the roof. The scene investigation did not reveal any signs of violence or disturbance to the scene, other than the efforts to rescue him by cutting the saline tube. According to eyewitnesses, the door was blocked from the inside by a chair. His clothes were not disturbed, and there were no visible injuries or blood marks on the body or in the room. The windows were closed, and they had fixed grills. The other end of the saline tube was tied to the roof, and it was cut, and there was a nylon rope tied to the same bar 30 centimetres (cm) from the saline tube. The nylon rope was torn and broken. According to the eyewitnesses, the saline tube was not wrapped around the neck; only a single loop was found on the anterior neck.

The autopsy revealed an averagely-built male clad in a sarong with a brown-coloured belt. A nylon rope was tied to the belt. There were no external injuries other than a skin contusion on the left side of the neck. There were no defence injuries or any other injuries. No petechial (tiny spots of bleeding under the skin or in the mucous membranes) haemorrhages at the eyes. No facial congestion, perioral/dental injuries, or petechial haemorrhages were observed. A faint ligature mark was noted 19 cm in size, 0.6 cm in width, and eight cm below the chin, extending backward and upward in an inverted ‘V’ shape. There were no underlying skeletal or muscle injuries. The lungs were heavy with moderately significant pulmonary edema (swelling of body tissues caused by excess fluid). Partially digested food was present in the stomach with an added aromatic odour of liquor. The musculoskeletal dissection did not reveal any deep muscle or skeletal injuries. Blood samples were sent to the Government Analyst for toxicological analysis, including the quantification of the serum alcohol levels.

During the reconstruction of the events, it was hypothesised that he may have tied the nylon rope around his belt after climbing on top of the cupboard and then tied both the saline tube and the nylon rope to the roof bar. He may have tried to control his weight during hanging by using the nylon rope, but unfortunately, it had broken. This may have tightened the saline tube around the front of the neck. He may have been incapacitated due to intoxication from alcohol consumption. The postmortem did not reveal any features suggestive of foul play. There were no suicidal notes, indicating that it may not have been a planned act. Finally, it was concluded that death was due to unintended asphyxiation from hanging following a para-suicidal attempt.

Conclusion 

The differentiation of para-suicidal attempts leading to death, homicide, accidental hanging, and sexual asphyxia is a major concern. Details from eyewitness statements, scene visits, circumstance analysis, postmortem examination, and event reconstruction play a major role in a similar scenario. It is a challenge for the forensic pathologist to decide whether the circumstance was accidental or suicidal, warranting the need for a ‘psychological autopsy’ in such ambiguous cases.