CASE REPORT
Medicolegal Investigations in Cases of Double Suicidal
Gunshots to the Head Using 2 Different Handguns
A Report of an Unusual Case
Carlo Moreschi, MD,* Ugo Da Broi, MD, PhD,* Leonardo Ciccone, MD,* and Tiziano Stocca, MD†
Abstract: Suicides committed by firing 2 gunshots to the head are rare
events and pose a significant challenge for coroners and forensic patholo-
gists. The evaluation of the victim's ability to fire 2 shots simultaneously, or
to act after a first gunshot, is crucial for the reconstruction of the death
scene and to differentiate between homicide and suicide. We report an un-
usual case of suicide involving 2 gunshot wounds to the head. The medico-
legal investigations hypothesized that the victim had either fired 2 shots near
simultaneously or he suffered from rapid incapacitation after the first gunshot
but was still able to fire a second consecutive and fatal shot to the head. This
article focuses on the diagnostic difficulties involved, together with analysis
of the death scene and autopsy findings, in cases where the courts demand con-
firmation that a double gunshot to the head is in fact a case of suicide.
Key Words: suicide, handgun, head gunshot
(Am J Forensic Med Pathol 2019;40: 266–268)
F irearm suicides generally involve the use of a single weapon and
only one shot. Suicides in which a single weapon fires more than
one shot have been described in the literature, with frequencies
ranging from 1% to 8% of total gunshot suicides.1–7 In these cases,
the weapon of choice is usually a handgun rather than rifles or shot-
guns (Blumenthal2 reported that a handgun was used in 96%,
whereas Kohlmeier et al1 in 78% of cases).3–11 Suicides involving
a single weapon, usually a semiautomatic pistol or revolver or more
rarely a rifle or machine-gun pistol, firing 2 or more bullets are
more frequent than cases involving 2 weapons.1,4–10 Instances of
suicides involving 2 or more shots fired specifically to the head,
as reported by Karger and Brinkmann,7 represent 3% of all cases
of firearm suicides and 45% of all cases of suicides in which 2
or more gunshots are fired to different areas of the body. Unfortu-
nately, there are few published statistical data describing the fre-
quency of suicides involving 2 weapons firing 2 or more times
to the head, but this type of suicide attempt would seem to be pre-
meditated and of high potential lethality.12 The presence of more
than one entrance wound in the head and the retrieval of 2 fire-
arms at the death scene are, as Perdekamp et al13 noted, extremely
rare and mean that reconstructing the dynamics of the event and
differentiating between suicide and homicide is complicated.2,3,13
Manuscript received October 31, 2018; accepted March 11, 2019.
From the *Department of Medical Area, Section of Forensic Medicine,
University of Udine, Udine; and †Department of Radiology, Gorizia
General Hospital, Gorizia, Italy.
The authors report no conflict of interest.
The authors report no funding received.
Reprints: Ugo Da Broi, MD, PhD, Sezione Dipartimentale di Medicina
Legale–Dipartimento di Area Medica, Università degli Studi di Udine,
Piazzale Santa Maria della Misericordia, 15-33100 Udine, Italy.
E-mail: ugo.dabroi@uniud.it.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions
of this article on the journal’s Web site (www.amjforensicmedicine.com).
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0195-7910/19/4003–0266
DOI: 10.1097/PAF.0000000000000487
266 www.amjforensicmedicine.com
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
The main challenge in such cases is to determine how the victim
could have fired 2 rounds from 2 separate guns simultaneously,
or fired a first shot that was then immediately followed by a second.
It is also crucial to determine whether the autopsy findings, includ-
ing morphology and location of the wounds, in conjunction with
the investigative information, are compatible with a suicide attempt.
Herein we report the unusual case of a suicide resulting from 2 gun-
shots to the head fired from a revolver and a semiautomatic pistol.
CASE REPORT
A 68-year-old man with hypertensive and ischemic heart dis-
ease and peripheral arterial disease suffering from serious depres-
sion had recently decided of his own accord to stop taking his
medication, both for the heart disease and for the depression.
Early in the morning, he was found dead inside his flat by
neighbors who were alarmed by the sound of gunfire. The body
was found lying on the floor parallel to the wall, clothed but with-
out shoes. The head rested on 2 towels, which were bloodstained
and had brain tissue and bone fragments on them (Photograph 1,
http://links.lww.com/FMP/A20). The right hand held an Arminius
38 4″ special revolver (licensed), which was resting against the
right shoulder with the elbow bent and propped on the floor (Pho-
tographs 1–2, http://links.lww.com/FMP/A20, http://links.lww.
com/FMP/A21). The muzzle was lying against the right side of
the base of the neck, and the index finger of the right hand was
bent around the trigger at an angle to the axis of the barrel. The
other 4 fingers held the grip. The left hand held a Carl Walther
PPK 7.65-mm semiautomatic pistol (unlicensed) and was resting
on the left side of the abdomen (Photographs 1–3, http://links.
lww.com/FMP/A20, http://links.lww.com/FMP/A21, http://links.
lww.com/FMP/A22). The elbow was bent and resting on the floor
(Photograph 1). The muzzle was pointing toward the upper body,
and the thumb of the left hand was bent around the trigger at an
angle to the longitudinal axis of the barrel. The other 4 fingers
were holding the grip. The cylinder of the revolver held one empty
cartridge and the bullet from this empty cartridge was found on the
floor, and approximately 7 cm up the wall beside the left side of the
head, there was a dent, 2 cm in diameter and 0.5 cm deep (Photo-
graphs 1–2, http://links.lww.com/FMP/A20, http://links.lww.com/
FMP/A21). One cartridge was missing from the Walther's magazine.
The clothes displayed the following stains:
-Bloodstains on both sides and at the back of the collar area
-Bloodstains on the upper part of the back of the shirt
-Blood spatters on the right and left cuffs of the shirt and on the
fingers of both hands
Small particles of gunshot residue were identified on the
victim's hands.
The presence of the victim's fingerprints on the firearms was
also confirmed.
Investigation revealed no recent suicidal ideations or suicide
note left, whereas the door of the flat was locked from the inside.
Am J Forensic Med Pathol • Volume 40, Number 3, September 2019
Am J Forensic Med Pathol • Volume 40, Number 3, September 2019
At the moment of the event, the man was the only occupant of the
flat, and the wife, who was outside the flat at the moment of the
suicide, reported that her husband never claimed to have suicidal
tendencies or attempts in the past.
The preautopsy computed tomographic scan revealed evi-
dence of 2 gunshot wounds to the head including fractures of the
cranial and basilar skull and extensive damage to the cerebrum.
Autopsy examination confirmed 2 gunshot wounds.
1. The first wound consisted of an entrance wound (A) in the right
temporal region, consisting of an area of tissue loss with a
roughly circular perimeter (2.5-cm diameter) with radial skin
tears and soot residues and a 1-cm-diameter hole in the bone
with soot residues on the periosteum (Photograph 4, http://
links.lww.com/FMP/A23) and an exit wound (B) in the left
frontotemporal region (Photograph 5, http://links.lww.com/
FMP/A24). The wound track appeared to course across the
frontal lobes with the presence of bone and metal fragments
along the trajectory between the hole in the right temporal re-
gion and the left frontoparietal area.
2. The second wound consisted of an entrance wound (C) in the
right parietal region, at the vertex of the skull, measuring
2-cm diameter with short radial skin tears and minimal soot res-
idues and a 1.5-cm-diameter hole in the underlying bone with
soot residues on the periosteum (Photograph 6, http://links.
lww.com/FMP/A25). The wound was associated with exten-
sive damage of the right parietal lobe, the occipital lobes, the
corpus callosum, the diencephalon, the left basal ganglia, the
midbrain, and the brainstem with bone and metal fragments
along the track between the hole in the right parietal and left oc-
cipital regions. The projectile then coursed through the occipi-
tal bone into the left paravertebral muscles in the neck, the left
scalene muscles, and the left trapezius, grazing the anterior up-
per surface of the left scapula, fracturing the posterior right
third rib, perforating the apex of the upper lobe of the left lung
and the lower left lung, before coming to rest at the level of the
left hemidiaphragm, where a bullet compatible with the semi-
automatic pistol was recovered (Photograph 7, http://links.
lww.com/FMP/A26).
DISCUSSION
When victims of multiple gunshot wounds are discovered,
the investigation is often difficult. Questions such as whether or
not the victim could fire the shots him/herself either simulta-
neously or in rapid succession need to be addressed. In the case
described previously, the investigative information led to the con-
clusion of suicide including the decedent's history of depression,
the locked apartment, absence of signs of a foul play (ie, struggle,
theft), and witness statements.
It may be hypothesized that the victim held the 2 guns, one in
each hand and either fired then simultaneously or in rapid succes-
sion. Considering the paths through the brain and the structures
damaged, namely, the bilateral frontal lobes, right parietal lobe,
the occipital lobes, the corpus callosum, the left basal ganglia, the
midbrain, and the brainstem, it is further hypothesized that the vic-
tim first fired the revolver (with its stiffer trigger mechanism requir-
ing the application of greater pressure), which damaged nonvital
brain structures, and then fired near simultaneously or consecu-
tively the semiautomatic pistol, which hit vital brain structures
and caused immediate death. The right and left frontal lobes hit
by the bullet fired from the revolver have a cognitive but nonvital
function, whereas the other areas hit by the semiautomatic bullet
(the midbrain and brainstem in particular) perform vital functions.
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Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Double Suicidal Gunshots to the Head
This is consistent with the argument of Karger14 and Karger
and Brinkmann7 that regarding cases of multiple gunshots to dif-
ferent parts of the body, the first gunshot (to the head or another
part of the body) can compromise the ability to act to differing de-
grees, which means that the victim may or may not be able to fire
the second shot.
The first shot may cause the following:
-Immediate incapacitation (lesions caused by severe tissue dis-
ruption to specific areas of the brain that control vital func-
tions), making the firing of a second shot impossible
-Rapid incapacitation (lesions to specific anatomical areas or or-
gans that perform vital functions, eg, heart, thoracic aorta, and pul-
monary blood vessels), which allows a very limited time to fire
a second shot
-Delayed incapacitation (lesions to specific anatomical areas or
organs, such as the lungs, liver, and spleen, that, if damaged,
lead to a delayed death) with a high probability of being able
to discharge a second bullet.7
According to a number of publications, death as a result of
brain injury caused by gunshot wounds may be inevitable, even
when structures that control vital functions are not involved, not
only because functions are compromised but also because of the
effects of hypoxemia after massive blood loss, intracranial hyper-
tension (caused by extensive bleeding), and cerebral edema.7–11
As reported by Hejna et al,11 the reconstruction of the crime
scene and the ability to distinguish between homicide and suicide
depend on the extent to which a victim was still capable after a
first nonlethal gunshot to the head, which might have allowed
him/her to fire a second shot to the head. One shot may not be im-
mediately lethal, meaning that the victim may be able to fire again,
even after a short time interval, for a second or more times.
This may occur, as Hejna et al write, when the bullet pene-
trates “mute” areas of the brain that do not control vital functions
(ie, the temporal and frontal lobes or when there is cross penetra-
tion of the frontal lobes), which means that the victim can still per-
form intentional acts. On the other hand, when the bullet penetrates
vital brain centers, that is, the brainstem, cerebellum, diencephalon,
midbrain (including the basal ganglia, the motor cortex, and the
internal capsula), motor cortex, and upper cervical spinal cord,
immediate capacitation and death will result.11,12,14,15
However, even when immediate incapacitation does not occur,
death may be inevitably caused by progressive brain hypoxemia due
to severe blood loss and consequent hypoperfusion, although the
oxygen stored in the central nervous system ensures a potential
for physical activity for approximately 10 seconds.11,16
Lesions to the sensory or optical areas of the central ner-
vous system have also been known to hamper the victim's abil-
ity to act.7
It is, however, difficult to accept the notion that 2 shots can
be fired from 2 different guns at exactly the same time. Such fire-
arms will have different trigger mechanisms requiring the user to
apply varying amounts of force for marginally different durations.
Only if identical guns were used might the victim have been able
to fire 2 perfectly simultaneous shots. Alternatively, as Padosch
et al17 wrote, the presence of 2 bullet tracks, both of which dam-
aged vital centers and caused immediate incapacitation, might
provide proof that the 2 bullets were fired simultaneously.
Moreover, it must be considered that most people have a
dominant hand preference: this factor would affect the occurrence
of 2 simultaneous or near simultaneous shots.
Medicolegal investigations should also include a comparison
of the seriousness of the anatomical lesions (including their histo-
logical features) and the force and speed of the bullets. Indeed
www.amjforensicmedicine.com 267
Moreschi et al
Arunkumar et al15 argued that the extent of penetrating head inju-
ries caused by gunshots depends on bullet speed:
1. Lower velocity projectiles produce direct primary tissue dam-
age characterized by a permanent track; they do not signifi-
cantly bruise or tear the surrounding tissue but can still damage
brain structures.
2. Higher velocity projectiles cause primary tissue damage, char-
acterized by a permanent track, but are preceded by sonic shock
waves: the total damage results from both direct primary tissue
damage and the transmission of the bullet's kinetic energy, which
produces a cavitation effect that may be significantly greater than
the size of the projectile and can significantly damage the ana-
tomical areas affected.
The final histological result, in any case, is a permanent track
with neuronal and axonal destruction in the surrounding areas.
Where high velocity projectiles are involved, the track is surrounded
by a narrow mantle-like zone with astrocyte destruction and
hemorrhagic extravasation resulting from radial acceleration and
tissue displacement.15
Therefore, the observation of permanent tracks with different
morphological and microscopic perilesional features may confirm
the use of guns having different firepower.
Jacob et al18 explained that to identify a suicide, it must be
proved that the fatal shot or shots were fired from within the victim's
reach and that they were in fact fired by the victim. Padosch et al17
pointed out that the possibility that a third party inflicted both gun-
shot wounds must always be excluded. Moreover, as reported by
Karger et al,5 because people attempting to shoot themselves gener-
ally try to ensure a stable and comfortable position for the shooting
hand, we always need to analyze the geometrical relationships be-
tween the body and firearm(s), to establish the position of the fire-
arm(s) at the moment of firing and the trajectory of the bullet(s).
CONCLUDING REMARKS
In summary, multiple gunshot suicides must be carefully in-
vestigated, as all suicides, including a meticulous scene and back-
ground investigation as well as medical history, social history, and
evidence of foul play, in addition to considering the autopsy find-
ings and whether or not it would be possible for the victim to fire
both shots.4,9,12,13,16–18
REFERENCES
1. Kohlmeier RE, McMahan CA, DiMaio VJ. Suicide by firearms: a 15-year
experience. Am J Forensic Med Pathol. 2001;22(4):337–340.
268 www.amjforensicmedicine.com
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Am J Forensic Med Pathol • Volume 40, Number 3, September 2019
2. Blumenthal R. Suicidal gunshot wounds to the head: a retrospective review
of 406 cases. Am J Forensic Med Pathol. 2007;28(4):288–291.
3. Bohnert M, Pollak S. Complex suicides—a review of the literature.
Arch Kriminol. 2004;213:138–153.
4. Hudson P. Multishot firearm suicide. Examination of 58 cases.
Am J Forensic Med Pathol. 1981;2(3):239–242.
5. Karger B, Billeb E, Koops E, et al. Autopsy features relevant for
discrimination between suicidal and homicidal gunshot injuries. Int J Legal
Med. 2002;116:273–278.
6. Eisele JW, Reay DT, Cook A. Sites of suicidal gunshot wounds. J Forensic
Sci. 1981;26:480–485.
7. Karger B, Brinkmann B. Multiple gunshot suicides: potential for physical
activity and medico-legal aspects. Int J Legal Med. 1997;110:188–192.
8. Boxho P. Fourteen shots for a suicide. Forensic Sci Int. 1999;101:71–77.
9. Hayashi T, Gapert R, Tsokos M, et al. Suicide with two shots to the head
using a rare ‘Velo-Dog’ pocket revolver. Forensic Sci Med Pathol. 2013;9:
265–269.
10. Balci Y, Canogullari G, Ulupinar E. Characterization of the gunshot
suicides. J Forensic Leg Med. 2007;14:203–208.
11. Hejna P, Safr M, Zátopková L. The ability to act—multiple suicidal gunshot
wounds. J Forensic Leg Med. 2012;19:1–6.
12. Kastanaki AE, Kranioti EF, Theodorakis PN, et al. An unusual suicide
inside a grave with two gunshot wounds to the head—the psychological
approach. J Forensic Sci. 2009;54(2):404–407.
13. Perdekamp GM, Nadjem H, Markel J, et al. Two-gun suicide by
simultaneous shots to the head: interdisciplinary reconstruction on
the basis of scene investigation, autopsy findings, GSR analysis and
examination of firearms, bullets and cartridges cases. Int J Leg Med.
2011;125:479–485.
14. Karger B. Penetrating gunshots to the head and lack of immediate
incapacitation. II. Review of case reports. Int J Leg Med. 1995;108(3):
117–126.
15. Arunkumar P, Maiese A, Bolino G, et al. Determined to die! Ability to act
following multiple self-inflicted gunshot wounds to the head. The Cook
County Office of Medical Examiner experience (2005–2012) and review of
literature. J Forensic Sci. 2015;60(5):1373–1379.
16. Newgard K. The physiological effects of handgun bullets. Wound Balist
Rev. 1992;1:12–17.
17. Padosch SA, Dettmeyer RB, Schyma CW, et al. Two simultaneous suicidal
gunshots to the head with robbed police guns. Forensic Sci Int. 2006;158:
224–228.
18. Jacob B, Barz J, Haarhoff K, et al. Multiple suicidal gunshots to the head.
Am J Forensic Med Pathol. 1989;10(4):289–294.
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