Egyptian Journal of Forensic Sciences (2016) 6, 478–480

H O S T E D BY Contents lists available at ScienceDirect

Egyptian Journal of Forensic Sciences

journal homepage: http://www.journals.elsevier.com/egyptian-journal-of-forensic-sciences

CASE REPORT

A planned complex suicide: Cut injury to the wrist

with corrosive acid poisoning
Sunil Gorakh Vidhate *, Harish Pathak, Manoj Parchake, Rajesh Sukhadeve,
Vikas Meshram

Department of Forensic Medicine and Toxicology, Seth G S Medical College and KEM Hospital, Mumbai, India

Received 23 July 2015; revised 1 October 2015; accepted 11 November 2015

Available online 8 December 2015

KEYWORDS
Planned complex suicide;
Cut wrist;
Corrosive poisoning;
Death scene investigation
Abstract A planned complex suicide is the complex action mechanism, formerly planned to pro-
tect the victim of suicide from failure. A 22-year old undergraduate student was found dead at his
home in the toilet with a cut injury to the left wrist. Autopsy findings revealed an incised wound at
the left wrist along with signs of corrosive acid poisoning. Death scene investigation confirmed it as
a case of planned complex suicide. To the best of our knowledge combination of methods used in
this case is unique and has not been reported previously. The sequence of events in this case was
difficult to determine as both the methods used viz. cut wrist and corrosive acid poisoning were suf-
ficient to cause death individually. Also the duration between the events must have been so less that
the sequence of events was difficult to be determined.
Ó 2016 The International Association of Law and Forensic Sciences (IALFS). Production and hosting by
Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).

1. Introduction victim so as to prevent failure of one of the mechanisms. On

A complex suicide is defined as the use of more than one method
to induce death, either simultaneously or chronologically. The
term has been widely accepted in the forensic literature.1,4,6,7
In 1974, Marcinkowski et al. had considered a general division
of methods of suicide. In this classification, suicides are divided
into simple versus complex, the complex one submitting to sui-
cide by a combination of more than one method.1,2,4,10–12
Planned complex suicide, or ‘‘primary combined suicide”, is
the complex action mechanism formerly planned, to protect
the victim from failure.5 This manner of suicide is used by the
* Corresponding author.
E-mail address: sunilvidhate95@gmail.com (S.G. Vidhate).
Peer review under responsibility of The International Association of
Law and Forensic Sciences (IALFS).
http://dx.doi.org/10.1016/j.ejfs.2015.11.002
2090-536X Ó 2016 The International Association of Law and Forensic Sciences (IALFS). Production and hosting by Elsevier B.V.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
the contrary, the characteristic of complex unplanned suicide,
or ‘‘secondary combined suicide,” is that the victim, after the
failure of an attempt, continues to try by using one or more
self‐destruction modalities to achieve death. A few cases of
planned complex suicide have been reported in the forensic lit-
erature and systematic studies are rare.1,5–7,9
2. Case report
A 22-year old undergraduate student, belonging to a ‘Telugu’
speaking family, was found unconscious at his home in the toi-
let. He was found in the supine position with his left hand
placed under a running tap water. An incised wound was pre-
sent over the anterior aspect of his left wrist. Blood stains were
present over the walls and floor of the toilet at places.
Following the incident, he was immediately brought to the
Cut injury to wrist with corrosive acid poisoning
Figure 1 Oozing of blackish coloured sero-sanguineous fluid
through nostrils.
hospital but was declared as brought dead. Post-mortem
examination was conducted on receiving the requisition from
the investigating authority. Examination of the clothes
revealed fresh blood stains at places. External examination
of the body revealed blackish coloured serosanguinous fluid
oozing out through the nostrils (Fig. 1). He was an averagely
built and nourished adult. Rigor mortis was present all over
the body but was not well developed. Post-mortem lividity
was present over the back of the trunk and buttocks but was
not fixed. A spindle shaped incised wound of size
6.5 cm  2.5 cm  tendon deep was present horizontally over
the anterior aspect of the left wrist. The margins were clean
cut and infiltrated with blood. The skin, subcutaneous veins
and fat, muscles, tendons, radial artery and median nerve were
incised. The radial artery was clean cut with a blood clot pre-
sent at the opening (Fig. 2).
Another injury, an abrasion of size 3 cm  1 cm was pre-
sent over the anterior aspect of the right knee with a bright
red scab in situ.
Internal examination revealed an inflamed and oedematous
oesophageal mucous membrane. The fundus of the stomach
was perforated. The gastric mucosa was inflamed, oedematous,
blackened and leathery to feel (Fig. 3). The peritoneal cavity
contained an estimated 150 ml of black grumos liquid mostly
formed of altered blood from the perforated stomach. All
other internal organs were pale. Samples of biological fluids
were taken for toxicological analysis that detected sulphuric
acid. Death scene investigation revealed a living room of size
Figure 2 Cut wrist wound; note clean cut margins and dissection
of underlying radial artery and median nerve.
479
Figure 3 Perforation of stomach; spilling of contents in peri-
toneal cavity, staining all abdominal viscera.
2.4 m  4.5 m with an attached toilet of size 0.6 m  1.2 m in
the left corner. The floor of the toilet was formed by designed
slippery wet tiles. There were few stains of blood over the floor,
walls of the toilet, near the tap and in the basin. A bottle of a
local toilet cleaner, labelled with contents mentioning sul-
phuric acid as one of the ingredients and a shaving blade were
found in a corner (Fig. 4). The edges of blade had blood stains
at places. A suicide note written in ‘Telugu’ language was also
found at his home. To the best of our knowledge this type of a
planned complex suicide, by using a combination of cut wrist
with corrosive acid poisoning, has not been reported
previously.2
3. Discussion
In the forensic literature, complex suicides account for about
1.5–5.0% of all suicides.2,15 Use of firearms has been earlier
reported as one of the most preferred methods employed in
complex suicide.7 Demirci et al. in their study have found that
most common methods of complex suicide were wrist cutting
Figure 4 Crime scene showing a shaving blade and an empty
bottle of toilet cleaner.
480
combined with self-strangulation, insecticide ingestion with
shotgun injury, and insecticide ingestion with jumping from
a height.2 Palmiere et al. have reported a complex suicide by
self-strangulation associated with multiple sharp force
injuries.3 In the literature, the use of maximum up to 5 suicidal
methods applied one after the other has been illustrated.13 Vic-
tims prefers to use methods of lesser lethality before choosing
to use more lethal techniques. The adaptation from lesser to
greater methods of lethality is most likely concerned with pain,
anguish, and frustration experienced by the person.11 Bohnert
and Pollak have accounted that self-inflicted injuries by sharp
force, especially cuts of the wrists, are often preferred as the
primary act of suicide in complex suicides.5,15 Demirci et al.
reported that wrist and/or flexor surface of the elbow cutting
was chosen in seven out of 16 cases in their study.2 In these
cases, subsequent method was applied because the first method
takes much time as well as gives pain and uneasiness. Hence,
the victim had selected the second and more lethal method
due to the reasons of pain, ache, and taking too much time.
Cingolani et al. have reported that even if hanging and shoot-
ing are frequently used alone in a planned suicide, their use at
the same time is rare.4
In the present case, a combination of methods was found as
cut injury to the left wrist with corrosive acid poisoning. In
most of the cases of complex suicide, wrist cutting was found
with other combinations.2 To the best of our knowledge, a
combination of cut injury to the wrist with corrosive acid poi-
soning has not been reported previously. In cases of sulphuric
acid poisoning, the time interval between acute ingestion of
sulphuric acid and death is known as lethal time (LT). The
LT min (minimum time after ingestion of fatal dose of a poi-
son that will cause death) is about 30 min and LT50 (time in
which 50% of persons will die after ingesting a fatal dose of
a poison) is about 5 h.8 Sulphuric acid ingestion will lead to
death by rapid cardiovascular collapse (within 30 min) or
shock secondary to gastrointestinal tract rupture related chem-
ical peritonitis (more than 4–5 h in 50% persons).8 If the victim
has died within 30 min after ingestion of the poison, then there
could not be signs of haemorrhagic shock. Hence, death in the
present case might have taken place more than 4–5 h after
ingestion of sulphuric acid. Also it takes almost 4–5 h for death
due to haemorrhagic shock after cut wrist injury involving the
radial artery. It indicates that, both these events, cut wrist and
sulphuric acid poisoning might have taken place very close to
each other in terms of time. Commenting on the sequence of
events in the present case is difficult. It can be just guessed
on the basis of previous studies that cut wrist injury might have
taken place earlier than ingestion of poison.2
Most of the questions may remain unanswered if the scene
of death is not investigated. The scene may disclose features
about suicide, like a suicide note or any material used as a
means of suicide. Relatives or friends of the decedent also
may reveal background information such as history of depres-
sion, previous suicide attempts, social, marital or economic
problems.14
4. Conclusion
A planned complex suicide represents a tricky medico-legal
case, because the combination of mechanisms concerned in
S.G. Vidhate et al.
such cases may be complex and homicide could be suspected.
Homicide should be carefully ruled out in every case of sharp
weapon injury. Only a careful assessment of all the elements,
including examination of the scene and post-mortem findings,
can reconstruct the lethal chain of events and elucidate the
time, manner, and cause and of death.
Funding
None.
Conflict of interest
None declared.
Ethical approval
None declared.
References
1. Marcinkowski T, Pukacka-Sokolowska L, Wojciechowski T.
Planned complex suicide. Forensic Sci 1974;3:95–100.
2. Demirci Serafettin, Dogan Kamal Hakan, Erkol Zerrin, Deniz
Idris. A series of complex suicide. Am J Forensic Med Pathol
2009;30:152–4.
3. Palmiere C, Risso E, van Hecke O, et al. Unplanned complex
suicide by self-strangulation associated with multiple sharp force
injuries: a case report. Med Sci Law 2007;47:269–73.
4. Cingolani M, Tsakri D. Planned complex suicide: report of three
cases. Am J Forensic Med Pathol 2000;21:255–60.
5. Pollak S. Zur Morphologie der Bolzenschubverletzung. Z
Rechtsmed 1977;80:153–65.
6. Hudson P. Suicide with two guns fired simultaneously. J Forensic
Sci 1982;27:6–7.
7. Blanco-Pampin JM, Suàrez-Penaranda JM, Rico-Boquete R,
Concheiro‐Carro L. Planned complex suicide. Am J Forensic
Med Pathol 1997;18:104–6.
8. Harchelroad F, Rottinghaus D. Chemical burns. In: Tintinalli JE,
Kelen GD, Stapczynski JS, editors. Emergency medicine: a
comprehensive study guide. New York, NY: McGraw-Hill; 2003.
9. Graham MA, Poklis A, Mackell MA, Gantner GE. A case of
suicide involving the concomitant intravenous injection of barbital
and oral injection of arsenic. J Forensic Sci 1983;28:251–4.
10. Turk EE, Anders S, Tsokos M. Planned complex suicide. Report
of 2 autopsy cases of suicidal shot injury and subsequent self-
immolation. Forensic Sci Int 2004;139:35–8.
11. Taff ML, Boglioli LR, Danto BL. Planned complex suicide. Am J
Forensic Med Pathol 1998;19:194.
12. Padosch SA, Schmidt PH, Madea B. Planned complex suicide by
self-poisoning and a manipulated blank revolver: remarkable
findings due multiple gunshot wounds and self-made wooden
projectiles. J Forensic Sci 2003;48:1371–8.
13. Grimm U, Sigrist T. Death by burning in open spaces. Death
caused be suicide or homicide? Arch Kriminol 1998;201:137–45.
14. Altun G. Planned complex suicide: report of three cases. Forensic
Sci Int 2006;157:83–6.
15. Bohnert M. Complex suicides. In: Tsokos M, editor. Forensic
pathology reviews, vol. 2. Totowa, NJ: Humana Press Inc.; 2005. p.
127–43.