One Hundred and One Cases of Plastic Bag Suffocation in the Milan Area Between 1993 and 2013-Correlations, Circumstances, Pathological and Forensic Evidences and Literature Review

Plastic bag suffocation and codeine overdose: An unusual case of complex suicide and review of the literature

The term "planned complex suicide" refers to cases where two or more suicide methods are applied simultaneously. Plastic bag suffocation is a suicidal method commonly combined with self-poisoning by inhalation of volatile compounds or pharmacological substances at poisoning dosage. A 67-year-old woman was found dead on the couch. The head was wrapped in a plastic bag knotted at the front of the neck. No signs of struggle were present on the scene. In the fireplace, there were two blisters of acetaminophen/codeine phosphate tablets. Postmortem examination showed congestion of the face and the neck and pulmonary edema with patchy emphysema. There was no evidence of physical duress. Toxic levels of codeine were detected in the blood. The death was related to a complex suicide involving codeine overdose and asphyxia by plastic bag suffocation. The hypoxic/cardioinhibitory effects of plastic bag suffocation combined to codeine-induced deep reduction of respiratory rate, making the suicide hypothesis the more likely scenario. In order to assess what elements contribute to postmortem diagnosis in complex suicides with plastic bag suffocation, a review of the forensic literature published between 2002 and 2022 was performed. This article emphasizes the complexity of diagnosing deaths involving plastic bag suffocation in suicides, particularly when combined with other methods like inert gas inhalation or drug intake. It underscores the importance of comprehensive toxicological analyses, careful scene examination, and histological studies, not forgetting a thorough comparative analysis of the existing literature, to accurately determine the cause and manner of death in such cases.

[As the Sunday Evening Crime-TV Leads to Death]

We report on a special case of suicide, which took place in near timely relationship to the broadcast of Sunday evening crime-tv-episode and copyed directly the therein displayed method of death. The problem of such presentations will be discussed either on behalf of the background of the german presscodex.

Complex and complicated suicides in Friuli (1993-2017)

Complex suicides involve more than one suicide method. According to the intention of the victim, they are classified as 'planned' when the use of more than one suicide technique has been previously devised by the victim and 'unplanned' when the first method turns out to be too painful or insufficient to cause death, and the individual then resorts to other means of suicide. Complicated suicide, on the other hand, is a term that was introduced by Töro and Pollak, in which a failed act of suicide is followed by traumatisation, which has a fatal outcome. This type of death must be distinguished from complex suicides. From a sample of 1160 fatalities (837 males) between 1993 and 2017, we identified 20 (1.72%) cases of complex suicide and three (0.26%) cases of complicated suicide. We considered age, sex, psychiatric history, previous suicide attempts, suicide methods and eventual secondary traumatisation. We also compared planned and unplanned complex suicides. The results show a higher number of planned complex suicides (16 vs. 4), a prevalence of males (n = 17) and adults (median age = 48 years, range 21-74 range). Plastic bag suffocation and gas inhalation (n = 8) were the most commonly used methods. Firearms (n = 4) were used exclusively by males in planned complex suicides. Wrist and forearm cuts (n = 5) were found in four unplanned and one planned complex suicides, and all of the cases with known previous suicidal attempts (n = 3) involved planned complex suicides. Complicated suicides concerned three male victims in two failed attempts of hanging and an unforeseen carbon monoxide intoxication following a non-fatal gunshot to the mouth, confirming the rarity of these fatalities.

A forensic analysis on 53 cases of complex suicides and one complicated assessed at the Bureau of Legal Medicine of Milan (Italy)

Complex suicides are highly uncommon suicides in which multiple detrimental methods are used simultaneously or in chronological succession. We retrospectively analyzed through our database the 25512 autopsy reports registered at the Bureau of Legal Medicine of Milan in the last 27 years from 1993 until 2019, where 4498 suicides were documented. We assessed 53 cases of complex suicides and only one case of complicated suicide: for all of them we analyzed both data collected during the on-site investigation and the autopsy. In our case series, we identified a total number of 113 methods chosen and variably combined by the victims, which were classified into 17 categories. On the whole the most frequent association of suicide methods resulted in the combination of the plastic bag suffocation with inert gas inhalation (13 out of 53 complex suicides; 24.5%). We also analyzed our cases of simple suicides (1993-2019), to compare them with the complex suicides. In this study, we present a complete analysis regarding our cases of complex suicides, discussing the challenges and the interpretative issues which a forensic pathologist might deal with. A thorough on-site judicial inspection and a careful autopsy examination are crucial in such cases. Moreover, the clinical history of the victims and laboratory findings are supplemental elements to be necessarily considered to establish the actual manner of death and avoid any misinterpretations.

Distinguishing between homicide and suicide knots and ligatures: A comparative analysis of case and survey data

Distinguishing between suicide and homicide can be challenging owing to ambiguous and confusing case details. In particular, there is a paucity of useful information comparing homicide and suicide knots and ligatures in the literature. Multiple knot and ligature characteristics have not been recognized previously because complete and accurate information has been lacking. Ninety external tying cases (mainly homicide) and 56 cases involving self-tying (mainly suicide) were reviewed to compare multiple knot and ligature characteristics. Additionally, 189 survey volunteers performed four standardized external tying tasks and two self-tying tasks, yielding comparison data from more than 1500 knots. Using all available data, it was determined that the differences between external and self-tying included types of knots, ligature configurations, ligature tensions, wrist gaps, wend lengths, knot access, external anchoring, and other indicators. These differences are presented in a proposed analysis checklist inspired by medical and psychiatric protocols. The checklist contains 14 potential characteristics for head and neck bindings, 14 potential characteristics for wrists and arms, nine ankle and leg characteristics, and four linkage details. The proposed checklist can be expanded and fine-tuned as more data are accumulated. It offers experienced knot analysts an additional tool to assist in drawing conclusions, which then can be related to other case evidence by investigators.

The forensic approach to plastic bag suffocation: Case reports and review of the literature

Death from plastic bag suffocation is unusual and rare in under-developed countries. Initially, deaths were accidental mostly of children but with time homicides, suicides and deaths in auto-erotic situations were noted. It is not always possible to discover the dynamics leading to the death especially when suicide is suspected. Often, the typical signs of asphyxia - petechial haemorrhages, facial congestion, oedema and cyanosis - are not there. The authors present two cases of plastic bag suffocation, where a multi-disciplinary approach was applied. This study reviews international literature on plastic bag suffocation, analysing the frequency of suicides, homicides and accidental deaths associated with plastic suffocation.

Suffocation Injuries in the United States: Patient Characteristics and Factors Associated with Mortality

Introduction

Asphyxiation or suffocation injuries can result in multi-organ damage and are a major cause of morbidity and mortality among different age groups. This study aims to describe characteristics of patients presenting with suffocation injuries to emergency departments (EDs) in the United States (U.S.) and to identify factors associated with mortality in this population.

Methods

We conducted a retrospective cross-sectional study using the 2013 U.S National Emergency Department Sample database. ED visits with primary diagnoses of intentional or accidental suffocation injury, and injury by inhalation and aspiration of foreign bodies or food (ICD-9-CM codes) were included. We performed descriptive statistics to describe the study population. This was followed by multivariate analyses to identify factors associated with mortality.

Results

We included a total of 27,381 ED visits for suffocation injuries. Most suffered from either inhalation and ingestion of food causing obstruction of respiratory tract or suffocation (51.6%), or suicide and self-inflicted injury by hanging, strangulation, and suffocation (39.4%). Overall mortality was 10.9%. Over half (54.7%) of the patients were between 19 and 65 years old. Males were more common than females (59.1% vs. 40.9%). Over half of the patients (54.9%) were treated and released from the ED. Factors associated with increased mortality included male gender, young age (4-18 years), diseases of the cardiac, respiratory, genitourinary and neurologic systems, intentional self-harm, and self-payer status.

Conclusion

Mortality from suffocation injuries remains high with significant burden on children and adolescents and on patients with intentional injuries. Tailored initiatives targeting identified modifiable factors through implementation of behavioral and environmental change can reduce the risk of suffocation injury and improve clinical outcomes of affected victims.

A particularly complex case of matricide by means of plastic bag suffocation: Case report

A rare case of homicide with plastic bag suffocation is presented in which forensic genetic investigations were carried out on the inner surface of a plastic bag placed over the head of an elderly woman, bedridden after a stroke. The results obtained suggested that she had been murdered and hinted at the perpetrator of the crime. In fact, it emerged that biological traces left by the victim matched those of her principal caregiver, her psychotic daughter, who later confessed to the crime. The old woman also had a son affected by a serious illness, whose genetic profile was found on the same bag. In a later interview, he stated that his sister had tried to kill him too, thus confirming the genetic findings and allowing the investigators to hypothesise that the daughter had used the same means to try to kill him. Based on these results, the usefulness of forensic genetic testing when investigating complex plastic bag suffocation deaths is highlighted. This peculiar case deserves interest, since no murder of this kind has ever been reported in the Italian forensic literature.