Review Article Complex suicides: A review of the literature with considerations on a single case of abdominal self stabbing and plastic bag suffocation $ Francesco Simonit a, *, Fabio Bassan a , Carlo Scorretti a , Lorenzo Desinan b a Istituto di Medicina Legale, Università degli Studi di Trieste, Ospedale di Cattinara, Strada di Fiume 447, 34146 Trieste, Italy b Dipartimento di Area Medica, Medicina Legale, Università degli Studi di Udine, p.le S. Maria della Misericordia 15, 33100 Udine, Italy A R T I C L E I N F O Article history: Received 26 April 2018 Received in revised form 13 July 2018 Accepted 25 July 2018 Available online 2 August 2018 Keywords: Complex suicide Stab wounds Plastic bag suffocation Forensic pathology A B S T R A C T Complex suicides are rare and consist in the use of more than one method to induce death, representing a challenging investigation for forensic pathologists. According to the several combinations reported in literature, they have been classified into “typical” (where two common suicide methods are associated) and “atypical” (where more than two methods, or infrequent combinations of suicide methods are involved). In the case discussed here, an elderly man suffering of depression was found dead inside the tool shed of his house with a knife embedded in the abdomen and two plastic bags fastened around the neck using a twine. Three other superficial stab wounds were clustered close to the penetrating lesion. Internal examination revealed haemorrhagic infiltration at the mesentery and haemoperitoneum. No evident signs of asphyxia were highlighted and the cause of death was attributed to haemorrhagic shock. This association of suicide methods has turned out to be unusual. A review of the literature concerning complex suicides, abdominal self-stabbing and plastic bag suffocation has been managed. Crime scene and details of the used tools, medical and psychiatric history of the victim and features of the internal and external lesions have been examined and compared to previous studies. Toxicological analyses were not performed. © 2018 Elsevier B.V. All rights reserved. Contents 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298 2. Case report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298 3. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298 3.1. Type of complex suicide and features of the victim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298 3.1.1. Epidemiological data, sex and age of victim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298 3.1.2. Psychiatric history and previous suicidal attempts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300 3.2. Features of the scene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300 3.2.1. Place and time of death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300 3.2.2. Sharp tool and plastic bags . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300 3.2.3. Elements concerning accidental plastic bag suffocation asphyxia in autoerotic procedures . . . . . . . . . . . . . . . . . . . . . . . . . . 300 3.2.4. Books and web chronology concerning suicide by plastic bag suffocation and farewell letter . . . . . . . . . . . . . . . . . . . . . . . . 300 3.3. Abdominal stab lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300 3.3.1. Clothes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300 3.3.2. Anatomical sites of the lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300 3.3.3. Number of lesions, orientation of the axis, hesitation wounds and defence wounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301 3.3.4. Internal lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301 $ This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. * Corresponding author. E-mail addresses: simonit.francesco@hotmail.it (F. Simonit), fbassan@units.it (F. Bassan), cscorretti@units.it (C. Scorretti), lorenzo.desinan@uniud.it (L. Desinan). https://doi.org/10.1016/j.forsciint.2018.07.027 0379-0738/© 2018 Elsevier B.V. All rights reserved. Forensic Science International 290 (2018) 297–302 Contents lists available at ScienceDirect Forensic Science International journal homepage: www.elsevier.com/locat e/f orsciint