Search

Murder-suicides are defined as the murder of at least one person and the suicide of the offender following the murder. The intention to commit suicide must be primary. In most cases, a male offender kills a female victim after a separation. The current analysis was the first analysis of the typology of murder-suicides in Berlin. We analyzed the autopsy files of the Institute for Forensic Medicine of the Charité University Medicine Berlin and of the City Institute for Forensic Medicine Berlin. We performed descriptive and statistical analyses of cases between 2005 and 2013. We identified 17 murder-suicides. All 17 offenders were male, and 20 of the victims (90%) were female. The offenders used firearms in the majority of the cases. In seven cases, the victims and offenders were at least 80 years old. The average age of the offenders was 63 years. Disease was the motive in 6 cases involving older offenders. Our study might support the development of prevention strategies. In this regard, it is important to build a database for murder-suicides in Germany and other countries, to formulate a uniform definition of murder-suicide, to carry out nationwide interdisciplinary studies on this topic and to improve the existing health care structures, especially for older adults and people with depression.

The role of psychoactive substances in the treatment of mental disorders and the risk of suicide are major public health issues. This cross-sectional study examined the prevalence of antidepressants and antipsychotics detected in toxicological screenings in suicides. Cases from the Institute of Legal Medicine of the Charité-University Medicine Berlin were reviewed over a 4-year-period. All cases (n = 477) with positive toxicology for antidepressants and antipsychotics in blood or organ tissue were included. Frequencies of the detected substances in non-suicide cases (n = 212; male n = 177, 55.2%; female n = 95, 52.5%) and suicide cases (n = 235; male n = 149, 63.4%; female n = 86, 36.6%) were examined. Tricyclic antidepressants (48.1%) were found most frequently in suicides, followed by atypical neuroleptics (37.0%), selective serotonin reuptake inhibitors (28.1%), typical neuroleptics (17.4%), tetracyclic antidepressants (16.2%) and other substances (8.9%). Alcohol was detected in 37.2% of suicides. The leading cause of death was drug poisoning (35.6%) followed by polytrauma (26.8%) and death by hanging (18.5%). A mental disorder (depression, schizophrenia, bipolar disorder, suicidality) was known in 22.9% of suicides. The most common location of death was the person's own house (63.8%) followed by public places (28.1%) and hospitals (8.1%) The five most common substances in the suicide group were doxepin (20%) citalopram (15.3%), mirtazapine (14.9%), quetiapine (13.6%) and amitriptyline (12.3%). Toxicological findings from cross-sectional studies provide insight into how often certain types of antidepressants and antipsychotics are associated with suicide. A complementary approach is valuable for assessing the risk of suicide during medical treatment because the various available approaches (analysis of suicidal behavior/ideation, toxicity of drugs) each have strengths and limitations.

Patterned bruising of the internal organs is unusual. In these cases a cutaneous pattern of bruising is not observed but the underlying tissue may show unusual injuries that may even be recognizable as a tramline pattern. We report the suicide of a 23-year-old man by jumping off a bridge. At autopsy, an unusual finding was "tramline" bruising of the right liver lobe. The "blunt objects" that inflicted the bruising were determined to be the right ribs which were pushed against the liver capsule as a consequence of the extensive thoracic and vertebral trauma after a fall from a height with intermediate impact.

We report an unusual case of suicide in which three 7.65 caliber projectiles were found in the single gunshot wound to the head of a 53-year-old man. Based on data collected at the death scene, CT scan, autopsy findings, and ballistics analysis, the events were reconstructed as follows: two 7.65 mm rounds had already been fired from the 9 mm Makarov pistol the subject was using but, being a smaller caliber, the cartridges had slipped forward and lodged within the barrel. When a third 7.65 mm cartridge was chambered and the gun fired for the third time, the nose of the last bullet hit the lodged bullets and all three rounds were propelled out of the muzzle in tandem as a single shot. Ballistic investigations confirmed that the kinetic energy of the three tandem bullets would have been sufficient to perforate the skull. In cases of gunshot wounds where the manner of death is unclear, a number of well-described circumstantial parameters, such as an atypical anatomical location of the gunshot, unusual firearm, or ammunition, as well as ambiguous autopsy findings, can raise doubts about the manner of death. In very rare cases, despite a single entrance wound, two or more bullets are recovered from the body, fired by the same weapon at the same time (the so-called "tandem bullet" phenomenon). Injuries by "tandem bullets" have crucial implications in gunshot deaths because of the mismatch between the number of entrance and exit wounds and the number of bullets found in or near the body.

First described in 1965, avulsion of the neural arch from the vertebral body of the axis (C2) as a sequel to violent and rapid hyperextension of the head was termed hangman's fracture because of its similarity to the injury observed after judicial hanging. Since diagnosing such a fracture at autopsy is difficult because of its anatomic position, accurate determination of features of a hangman's fracture in cases of non-judicial hanging has not been systematically elucidated. We performed a prospective autopsy study visualizing hangman's fractures in 32 cases of hanging using postmortem multislice computed tomography (pmMSCT). A hangman's fracture with a fracture of the vertebral arch adjacent to the C2 vertebral body was only detected in one case (3.1 %). In this case a rarely observed longer drop with a lateral knot was used. Although a hangman's fracture was invariably observed bilaterally in previously reported cases, our case revealed a unilateral fracture at the side corresponding to the location of the knot. Out of the three types of hangman's fracture, pmMSCT is especially useful for detecting type 1 (nonangulated, undisplaced C2 with a normal disk at C2/C3). Also, pmMSCT is superior to conventional radiography in diagnosis, especially when the fracture is extending into the transverse foramen. In conclusion, pmMSCT imaging is useful for detecting hangman's fracture in hanging cases. Accumulating more evidence through pmMSCT will allow clarification of the actual incidence and circumstantial findings of hangman's fracture that have been controversially debated for many decades in the forensic community.

This report demonstrates how carbon dioxide (CO(2)) may be a potent weapon in murder-suicide, where the death scene offers virtually no clues as to the lethal modality and the autopsy findings are nonspecific. Four bodies were discovered in an apartment in midsummer 2012 in Berlin, Germany. The bodies were those of a father (a 69-year-old business consultant), his wife (aged 26-years), and two sons (aged 3 and 6 years, respectively). The police found the wife and two sons lying in their beds and the husband in a supine position on the floor with a plastic bag over his head tied loosely around his neck with a rope. A 500 g single-use CO(2) cylinder was standing on the floor. The container was almost empty and according to the label had been sold as a CO(2)-fertilizer for aquarium plants. Two synthetic inhalation face masks and tubing were also found, which tested positive for the DNA of all four deceased family members. It is hypothesized that the husband placed an inhalation mask over the mouths and noses of his wife and children while they were sleeping. Inhalation of pure CO(2) ensured their rapid unconsciousness due to hypercapnia and severe anoxia. The rapid increase in CO(2) concentration would render a victim helpless, with no time to wake and defend themselves, or others. The proximate cause of death in all cases was attributed to CO(2) intoxication, based on the scene findings, the reconstructed sequence of events, the autopsy, and results of toxicological studies.

Multiple inflicted injuries in traumatic deaths usually indicate homicide. Three cases are reported where homicide was initially suspected due to findings at the death scene and the apparent nature of the injuries however, after investigation, involvement of any other individuals in the deaths could be excluded. Case 1: A 52-year-old male was found with multiple stab wounds. At autopsy, 36 stab wounds were identified, the majority of which were superficial. Only two stab wounds had penetrated deeply. Case 2: A 19-year-old female was found with three gunshot entry wounds to the right temple and a .22 calibre automatic rifle resting across her lap. Case 3: A 47-year-old female was found with numerous haematomas and three deep head wounds in keeping with trauma from impact with a blunt object. A high level of clozapine was detected on toxicological analysis of blood and a history of schizophrenia was reported. Although multiple self-inflicted wounds are most often caused by sharp objects such as knives, on occasion multiple gunshot wounds and rarely, blunt trauma may also be encountered. Careful integration of scene and autopsy findings may be required to avoid misinterpretation of the circumstances and manner of death., (Copyright © 2013 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Diphenhydramine (DPH), an H1-antihistamine, is identified during postmortem toxicological analyses on a relatively rare but still regular basis. This study examines suicidal intoxications with DPH by analyzing blood and gastric content concentration levels. Twenty cases of DPH intoxications within a 10-year period (2000-2010) were discovered by screening the autopsy records of the Institute of Legal Medicine and Forensic Sciences (ILMFS) in Berlin, Germany. In four cases, DPH levels were lower than 1 μg/mL and hence were not considered likely to be responsible for causing death. In 11 cases, DPH played a role in the fatal episode, and five of these cases were monointoxications. Considering that more than 8,000 autopsies were performed by the ILMFS within the time period under examination, there is only one monointoxication case every 2 years, which makes it a rare occurrence. In two of these intoxications, DPH was only measured in toxic but not "lethal" concentrations in blood, with a concentration of 5 μg/mL being generally used as the cut off between categories according to forensic literature. This raises the question as to whether a strict boundary for a "lethal" blood concentration, as suggested in some literature, can be set and applied in any of these cases. This study shows that an individual interpretation of each case is of utmost importance for correct classification. A thorough toxicological analysis of peripheral venous blood and gastric content, as well as a detailed work-up of the death circumstances, are the basis of an exact interpretation of intoxications with DPH.

For a better understanding of circumstantial and toxicological findings of fatalities resulting from self-administration of intravenous anesthetic/narcotic agents, medico-legal autopsy files of the State Institute of Legal and Social Medicine Berlin from 1998 to 2011 were reviewed retrospectively. Of a total of 15,300 autopsies, 9 cases of such deaths were identified, and all were health care professionals. Medical supplies for injection were found still on, or near, the body at the scene. Anesthetic/narcotic agents detected were classified into 3 categories, and administered solely or in combination. Propofol was the most common agent, being detected in 6 cases. In 2 out of 6 cases, propofol was detected substantially above therapeutic levels and was considered the cause of death. In the remaining 4 cases, propofol levels were within the therapeutic range, but propofol intoxication was considered as lethal due to it being administered by rapid continuous injection. In 5 cases, injection of opioid narcotics was fatal. Alongside the 2 propofol-detected cases, there was one case where a higher-than-therapeutic level of piritramide and a therapeutic level of alfentanil was identified. Despite suspected usage, remifentanil was not detected due to its rapid metabolism by elastases in one case, and sufentanil was undetectable due to putrefaction in another, but death was attributed to their potent respiratory depressant effects without respiratory assistance. Benzodiazepines were detected in 4 cases. All of them were used together with propofol or opioids, and contributed to death by inhibiting respiration. It is essential to consider means of administration as well as additive or synergistic effects of combined agents when interpreting toxicological results in such cases.

We describe and discuss haemorrhages discovered in the back and auxiliary breathing muscles of a population of cases of suicidal death by hanging. Intramuscular haemorrhages were present in approximately 30% of the cases. Pre-existing illnesses with an increased tendency to bleed or an anticoagulant medication did not exist; corresponding skin and subcutaneous fatty tissue structures were intact in each case. In cases of death by hanging, the occurrence of muscle haemorrhages of this type may be explained pathophysiologically by the occurrence of increased respiratory exertions and/or seizures during the hanging process. Although the results of our study do not indicate an obligatory autopsy finding, evidence of internal haemorrhaging into the back and auxiliary breathing muscles may be called upon following consideration of differential diagnostic aspects as a further diagnostic indication of vital hanging.

We describe and discuss autopsy findings of bowel wall hemorrhage in a study population comprising cases of suicidal death by hanging. Intramural hemorrhages were seen in approximately 12% of the cases examined; no preexisting bowel diseases were found. In hanging deaths with a longer agonal phase, we opine that abdominal congestion during the hanging process provides a viable pathophysiological explanation for bowel wall hemorrhage. Though we are not dealing here with obligatory autopsy findings, the detection of bowel wall hemorrhage might be used as another sign of vital hanging after considering differential diagnostic aspects.

A fatal case of multidrug poisoning by tramadol and nicotine is reported. Tramadol is a centrally acting analgesic used in the treatment of moderate to severe acute or chronic pain. Nicotine, a lipid-soluble alkaloid, is one of the most readily available drugs in modern society. A 46-year-old man was found dead in his bed, and a suicide note was discovered near the body. He had 25 transdermal nicotine patches attached to his thorax and abdomen. Two half emptied bottles were found on the bedside table; the toxicological examination revealed that they contained tobacco and nicotine as well as other drugs such as diphenhydramine. At autopsy, areas of fresh and old myocardial infarction as well as diffuse pulmonary congestion and edema were present. The tramadol concentration was 6.6 microg/mL in femoral venous blood, while levels of nicotine and its primary metabolite cotinine were determined to be 0.6 and 2.0 microg/mL in femoral venous blood. Based on these results, we determined the cause of death to be cardiorespiratory failure induced by the additive effects of tramadol and nicotine shortly after consumption., (2009 Elsevier Ireland Ltd. All rights reserved.)

The number of fatal carbon monoxide poisonings has significantly decreased since the introduction of natural gas. Apart from their occurrence during house fires, accidental and suicidal carbon monoxide poisonings are only rarely seen nowadays. We report on 7 cases of unintentional and intentional fatal carbon monoxide poisoning (CO-Hb concentrations between 56.4% and 74%) due to improper handling of charcoal fires in closed spaces. Autopsy findings and results of the toxicological analysis are presented and discussed.

When the situation at a death scene is unusual, this may suggest the involvement of another person. On the other hand, one also has to consider the possibility of a conscious or unconscious behavior in connection with extreme stress situations or suicidal acts. The forensic findings and criminalistic reconstruction of two cases of suicidal burrowing behavior are presented and discussed.

A 7-year-old boy was killed by his father by manual strangulation during a murder-suicide. After the killing of the son, the father showed typical "undoing" behaviour: He changed the boy's clothes and laid him down on the bed. Then he placed candles around his head, put pictures of the parents' wedding around him and a crucifix and a picture of the family into his hands. He broke off a rose in a vase next to the bed, lit the candles and took photographs of his dead son. Later he called his wife, threatened to kill the son and finally called the police to confess the murder and to announce his forthcoming suicide.

A 78-year-old hunter was found dead beside his raised hide with a gunshot wound to his chest. In the present case, the reconstruction of the shooting event revealed an accident. Disregarding all safety rules, the hunter had placed his superposed rifle-shotgun on the chair and pulled the barrels of the cocked gun towards his body. One of the triggers interlocked with the button of a camping chair's cushion and a shot was fired. Furthermore the morphology of wounds from shotgun slugs is discussed on the basis of the autopsy findngs.

A rare case of vehicle-assisted suicide in a 43-year-old man is presented. The man had tied a rope between a fence and his neck and, while seated on the driver's seat, accelerated the vehicle, which resulted in complete decapitation. Earlier that day, the man had tried to bleed himself to death by bottling his own blood in his flat, thus defining the case as secondary complex suicide.

Fatal monointoxications with benzodiazepines, for instance with a suicidal intention, are exceptional findings. We report the autopsy case of an 82-year-old woman who died due to a suicidal monointoxication with Rohypnol 1 mg film tablets (therapeutical agent: flunitrazepam). 0.065 mg/L flunitrazepam and 0.34 mg/L 7-aminoflunitrazepam were detected in a postmortem heart blood sample and toxicological analysis revealed the metabolite 7-aminoflunitrazepam in gastric contents, too. At external examination, a bluish-turquoise coloration was seen around the woman's right nostril and within the oral cavity. At autopsy, similar coloration phenomena were seen on the mucosa of the distal esophagus and the stomach. Formerly, bluish stains on mouth and nostrils were considered indicative of intoxications with organophosphates such as parathion (E 605). More recently, case reports accumulate where an intoxication with Rohypnol 1 film tablets (containing the coloring agent indigocarmine in its core) have to be considered as a potential differential diagnosis of such coloration phenomena.

Despite high suicide rates all over the world, complete decapitation as a consequence of violent suicide methods is exceptionally rare and there is always a potential for confusion with homicide as well as with body dismemberment or mutilation. We analyzed the phenomenology and morphology of 10 cases (six male, four female; individual age 18-60 years) of suicidal complete decapitation that were subjected to medico-legal autopsies at the Institute of Legal Medicine, University of Hamburg, Germany, between 1995 and 2002. All decapitations occurred while the person was alive as proven by signs of vitality. Blood alcohol levels were positive in five cases and ranged between 28 and 202 mg/dl. The applied methods of suicide were running over by a train in eight cases and hanging in two cases. In suicidal hanging resulting in complete decapitation the wound margins were clear-cut with an adjacent sharply demarcated circumferential band-like abrasion zone showing a homogenous width, the latter determined by the thickness of the rope. In decapitations due to railway interference a broad spectrum of pathologic alterations such as the co-existence of irregular, ragged and sharp-edged wound margins, vascular and nervous pathways forming bridges in the depth of the wound and bruising could be observed. In such cases skin abrasion zones were generally not circumferential and showed a heterogenous width. Concerning hanging-related complete decapitations, our findings are well in line with those of other authors, namely that heavy body weight of the suicidal, fall from a great height and in some cases inelastic and/or thin rope material used for the noose are the determining factors decisive for complete decapitation.

Two cases of planned complex suicide are presented. In both cases, the suicidal persons shot themselves after making sure that in the sequel their bodies would be burnt. In the first case, a 65-year-old man had shot himself in the mouth and consequently fell into a fire he had lighted before. In the second case, a 43-year-old man set fire to his flat and shot himself directly afterwards. On the basis of the reported cases, a short literature review on planned complex suicides is given.

Under forensic differential diagnostic aspects postmortem findings of adhesive tape in the face suggest either suicide, an autoerotic accident or homicide, in which case the adhesive tape could have been used for sealing the mouth or as a means to commit the homicide itself. 9 autopsy cases are described as examples with this constellation and discussed under criminological aspects.

Suicidal explosions that lack a terrorist background are only rarely encountered in the field of forensic pathology. The investigation of explosion-related fatalities can be a substantial challenge in medicolegal casework. Determining whether the manner of death is suicide, homicide, or accident in such cases can present an especially difficult task to the forensic pathologist. This study considers the pathologic features of suicidal deaths caused by explosives without a terrorist background. The modus operandi of the decedents reflected familiarity and proficiency, or at least a degree of specialized knowledge, with the construction and use of explosive devices. All explosions were set off in confined spaces. The injury patterns consisted of a combination of primary blast injuries (e.g. decapitation, traumatic amputation of limbs, gross lacerations of the body surface, blast injuries of gas-containing and hollow organs), secondary blast injuries (e.g. splinter-induced penetrating trauma), tertiary blast injuries (e.g. abrasions and contusions), and burn injuries (mostly of the flash type). The previously described symmetric distribution pattern of injuries in suicidal explosions was apparent only to a certain degree in the present series. Our observation of superficially sharp-edged wound margins with bridging in the depths of the lesion in blast-induced lacerations of the skin should deserve further attention in forthcoming cases of explosion-related fatalities because this finding is a diagnostic possibility that may support the theory of an explosion-related fatality under special circumstances, e.g. when the body has been dumped away from the place of death. Because a terrorist attack may be initially suspected in each case of suicide involving explosives, the importance of a joint inquiry based on expertise from police investigators, bomb experts, and forensic pathologists is evident.

The authors report on three autopsy cases in which the findings at the death scene gave rise to the suspect of non-natural, in two cases even violent causes of death. The medico-legal and criminalistic investigations led to surprising results: Death was due to acute intoxication with narcotics, supposed delirium tremens and a suicide attempt in the presence of bronchopneumonia. External force was ruled out in all three fatalities by cooperative work of police investigators and forensic medicine.

So-called exit bags are voluminous, transparent plastic bags, each with a collar to go round the neck, and a Velcro fastening. In conjunction with the consumption of sleeping pills, the bags are recommended as an aid to commit suicide by organizations in favour of "humane death". It is reported on four such suicides by elderly people between 79 and 87 years of age. In two of these cases, there was assistance in committing suicide, one corresponding to a suicide protocol from the Swiss organization for euthanasia, EXIT. In two cases, detailed instructions for committing suicide were found. The morphological findings were not very specific in any of the cases. If the plastic bags are removed by a third party, this type of suicide may remain undetected even after performance of an autopsy. Exit bags tend to be used by older people with either real or feared life-threatening illnesses, in suicides which have usually been planned for some time. From the criminological point of view, the possible active participation of other persons in pulling the covering over the head can often not be proved. Assisting a suicide, in the sense of giving instructions on how to accomplish it, is not punishable in German law.

Fatalities caused by electrocution often lack specific morphologic evidence. Investigation of the death scene along with technical inspection of the electrical apparatus may help in clarifying the cause and manner of death. Cutaneous current marks may be the only sign of low voltage associated fatalities. The authors report a case of an electrician who committed suicide by electrocution using a time switch after oral ingestion of diazepam. Electrodes (coins) were fixed with adhesive tape at the height of the heart to the front and back of the left side of the chest. Autopsy revealed a blackish linear mark on the pleura parietalis of the inner side of the thoracic cavity, connecting the cutaneous current marks. Current-related and heat-related changes, such as hypercontraction bands of the intercostal muscles and coagulative changes of the perineurium of peripheral nerves, were found at histologic examination. Taking into consideration that the body had been under the influence of low-voltage current for 7 days, the morphologic alteration on the pleura parietalis was in accordance with an internal current mark, indicating the main route of current flow through the body. To the authors' knowledge, such a current-related phenomenon has not been reported to occur on an inner body surface before.

Suicidal electrocution using a time switch is relatively rare. Based on two cases from the authors' own forensic material and seven cases from literature peculiarities regarding the concomitant intake of medicines (benzodiazepines) and alcohol are discussed and comments are made how to proceed in the criminal and forensic investigation of such cases.

A 68-year-old non-diabetic physician with a known psychiatric history was found dead in his home. The death scene investigation revealed three used insulin syringes on the coffee table next to the body. The autopsy and the consecutive chemical-toxicological investigation revealed that the deceased committed suicide by injecting an overdose of insulin in combination with a high therapeutic oral bolus application of a beta-blocker (Metoprolol). A surprising morphological finding was a terminal pulmonary thromboembolism in the right pulmonary artery.