Analysis of a Rare Case of Complex Suicide Involving Hanging and Abdominal Cuts: A Case Report

Introduction

Suicide, defined as the deliberate act of ending one’s own life, is a major global public health concern.^{1, 2} Suicide methods include, but are not limited to, suffocation or hanging, poisoning or drug overdose, injuries from firearms, drowning, leaping from high places, stabbing, and other techniques, with hanging being the most prevalent in developing countries.^{3, 4} Individuals who commit suicide may opt for a single method, referred to as simple suicide, or they might employ a combination of two or more methods, either simultaneously or sequentially, which is termed complex suicide. ⁵ Complex suicide is a rare and intricate occurrence, accounting for 1.5%–5% of all suicide cases. ⁵ Nevertheless, forensic experts face considerable difficulties in differentiating it from other homicides or accidents. ⁶ Complex suicides may involve several injuries, a mix of methods, atypical situations, or unusual wound types that are not characteristic of straightforward suicides and may resemble those from an assault.^7–9 In addition, the absence of clear suicide indicators, such as a missing suicide note or weapon at the scene, can complicate the confirmation of suicide and may lead to suspicions of murder or accidental deaths. ¹⁰ The staging of crime scenes in murder cases, where offenders might arrange the scene to look like a suicide when it is actually a homicide, adds another layer of complexity to the discrimination. ¹¹ Another crucial challenge is the need to integrate various data sources, which may not always be easily accessible, including the deceased’s medical and psychosocial history and the circumstances of death, with autopsy findings. ¹² This necessitates a thorough multidisciplinary postmortem investigation approach involving forensic pathologists, investigators, and other experts in the field.^{13, 14}

This case report concerns a rare instance of complex suicide involving both hanging and self-inflicted abdominal cuts. The aim of the study is to understand the importance of using a multidisciplinary approach in postmortem investigations to distinguish complex suicide cases from potential homicides or accidents. By examining the deceased’s medical history, crime scene findings, autopsy results, and circumstances of death, this study enhances the understanding of complex suicide techniques and their significance in forensic practice.

Case Presentation

A 48-year-old right-handed male was found dead hanging from a tree in a wooded area close to his residential area. Five years prior, the patient was diagnosed with a depressive disorder and was prescribed antidepressant medications. However, over time, it became apparent that the patient was not consistently following the prescribed treatment. The patient then disappeared after he was last observed to be in relatively good health. Thereafter, he inflicted several superficial cuts on his abdomen and ultimately ended his life by hanging himself from a tree using his shirt as a ligature. He was then found deceased, hanging from a tree, 10 hours after he went missing, and an autopsy was conducted the day after his body was discovered. No evidence of suicide notes or sharp materials was detected at the death scene. The patient had no history of substance abuse or other long-term medical conditions and was a married man living with his family. The body was fully suspended by the shirt, with the feet 30 cm above the ground, and there was no evidence of recent damage or disturbance to the dressing. Dried blood stains were detected on the fingertips of the left hand.

External examination revealed a shirt ligature material entangled over the neck, with the right sleeve encircling the neck and the left sleeve forming the suspension part (Figure 1). A 38 cm × 01 cm × 0.6 cm dark brown oblique incomplete ligature mark was revealed encircling the neck above the thyroid cartilage, which extended upward and laterally to the left and faded on the left lateral side (Figure 2). The ligature mark was positioned 08 cm below the center of the mandible, 06 cm below the right external auditory meatus, and 11 cm below the occipital protuberance, with swollen and subtle hemorrhagic edges and a furrowed, dry base. The ligature material measured 115 cm in its suspension part and 42 cm in its encircling part, showing no signs of tears or blood stains. No dried saliva stains were observed around the mouth, neck, or on the T-shirt or the ligature. The tongue, lips, and fingernails appeared cyanotic, and the tip of the tongue was trapped between the tightly clenched teeth. The abdominal wall showed eight superficial, closely spaced, horizontal, and roughly parallel overlapping incised wounds 03 cm above the umbilicus traversing the midline and tailing to the right, with one more pronounced and deeper wound in the center (Figure 3). The wounds were clean-cut, everted, and a combination of linear and spindle-shaped without significant staining of the spurted blood. In addition, two superficial, shallow, and horizontal incised wounds were noted in the right upper quadrant of the abdominal wall, tailing to the right (Figure 3).

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Figure 1.

The Body on the Autopsy Table Showing a Shirt Ligature Material (the Deceased’s Own Shirt) In Situ Over the Neck, with the Right Sleeve of the Shirt Encircling the Neck (Red Arrow) and the Left Sleeve Forming the Suspension Part (Yellow Arrow).

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Figure 2.

A Parched Oblique Ligature Mark Encircling the Upper Third of the Neck With the Following Features; A: Faded Part of the Ligature Mark Located Over the Left Lateral Side of the Front of the Upper Third of the Neck (Yellow Arrow) Extended to the Upper Third of the Left Posterolateral Aspect of the Neck (Blue Arrow); B: An Abrasion Knot of the Ligature Mark Located Over the Left Submental Area (Red Arrow); C: Front of the Upper Third of the Neck Showing a Pronounced Oblique Ligature Mark Directed to the Left and Upwards (Blue Arrows); D: Furrowed Ligature Mark Located Over the Right Posterolateral Aspect of the Upper Third of the Neck Directed Upwards and to the Back of the Neck (Green Arrow).

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Figure 3.

Abdominal Self-inflicted Incised Wounds Composed of Multiple Horizontal Sharp Weapon Strikes Located Over the Abdominal Wall Crossing the Midline Showing Multiple Superficial Hesitation Cuts Originating From the Left Side of the Abdominal Wall Below the Umbilicus Directed to the Right Side Ending on the Right Side of the Abdominal Wall (Red Arrows), Coalescing at the Midline Making One More Pronounced and Deeper Cut in the Center (Yellow Arrows), and Two Faint and Horizontal Self-Inflicted Incised Wounds on the Right Upper Quadrant of the Abdomen (Blue Arrows).

Internal examination of the neck revealed dry, shiny, and pale tissues underneath the ligature mark, with no hemorrhage in the muscle compartments. The hyoid bone and thyroid cartilage showed no evidence of fracture. The abdominal wounds were confined to the superficial skin layers. Other examination findings were normal. Blood, stomach contents, bile, and urine samples were collected for drug and toxicology screening, which yielded negative results for all samples. The autopsy report concluded that the cause of death was hanging, the manner of death was determined to be suicide, and the abdominal incised wounds were classified as self-inflicted.

Methodology/Methods

We conducted a retrospective analysis of the crime scene, circumstantial investigation, autopsy, and records of the case and reviewed pertinent literature. A detailed crime investigation was conducted, which included an examination, photographic documentation, and collection and preservation of physical evidence. An in-depth review of the deceased’s medical and psychosocial history was undertaken, involving an examination of available medical records and interviews with family members and health care providers. Forensic autopsy was conducted at the Rwanda Forensic Institute located in Kigali, the capital of Rwanda. Written informed consent for the autopsy procedure and associated research and publication of findings was obtained from the deceased’s bereaved family and the requesting authority before the commencement of the autopsy. A forensic autopsy was performed, which entailed a detailed description of external features, documentation of ligature marks, abdominal wounds, and other findings, measurement and photography of all visible injuries, along with a systematic examination of all organ systems and internal structures, and a detailed analysis of neck structures and abdominal injuries. In addition, blood, urine, bile, and gastric content samples were collected for screening for drugs, alcohol, and other substances. The Research and Community Service Council Ethical Review Board of the Rwanda Forensic Institute granted ethical approval for this study. Furthermore, official permission was obtained from the Forensic Medicine Division of the Rwanda Forensic Institute, from which the autopsy records were accessed. The institution’s administration was briefed on the study’s purpose, expected benefits, and data collection methods. The information was kept confidential, and all identifying details were anonymized.

Discussion

Complex suicides present a significant challenge in forensic practice, requiring forensic experts to exercise great care in differentiating these cases from those that are homicidal or accidental.^15–17 To our knowledge, reported cases of complex suicide involving suicide by hanging and self-inflicted abdominal incised wounds are scarce.

In our case, the autopsy revealed multiple shallow and horizontal sharp weapon strikes on the abdominal wall, with dried bloodstains on the fingertips of the left hand. The wounds started on the left side of the abdomen and ended on the right side, traversing the midline. The incised wounds coalesced in the middle, forming a more pronounced and deeper, irregular horizontal cut. Hesitation wounds are self-inflicted superficial sharp-force injuries inflicted after deciding not to commit suicide or muster courage before making a final, fatal wound.^{18, 19} Abdominal hesitation cuts are often found in the upper abdominal wall, accessible to the victim’s hand, and follow a horizontal pattern.^{20, 21} In this study, the location and pattern of the wounds, coupled with the fact that the deceased was right-handed, indicated that the injuries were self-inflicted. In addition, the findings suggest that the victim likely used a sharp object with his right hand and touched the wound with his left-hand fingertips, probably because of intense pain, before ultimately hanging himself. These observations are consistent with previous findings indicating that victims of complex suicide may employ less lethal methods before resorting to more deadly techniques, possibly due to frustration, uncertainty about their chosen method, anguish, or assessment of their pain tolerance before inflicting a fatal injury. ²²

Moreover, the current case revealed an oblique ligature mark situated above the thyroid cartilage, with the victim’s own shirt serving as the ligature material, and with no evidence of struggle that aligns with the features of suicidal hangings, unless in some atypical scenarios. ²³ In cases of homicidal hanging involving healthy adults, victims usually resist, leading to injuries to their body parts, disturbances to clothing, or the scene. ²⁴ Furthermore, individuals who are unconscious or under the influence of a drug can be hung by someone else without significant resistance, which can make it challenging to differentiate them from self-hanging. ²⁵ In this case, the determination of self-hang was supported by the presence of a ligature mark characteristic of suicidal hanging, coupled with the lack of defensive or offensive wounds, signs of restraint, disturbance to clothing or scene, and any other evidence of another person’s involvement. Furthermore, the negative results from toxic substance tests and the absence of any serious medical condition that could alter the individual’s consciousness support ruling out the state of unconsciousness of the victim. Because of their low lethality, individuals with self-inflicted abdominal incised wounds may perform voluntary or involuntary actions that can obscure the crime scene, making it difficult to trace the sharp weapons used, thereby complicating the determination of the manner of the resulting injuries. ¹⁸ As a result, the lack of recovery of a sharp instrument from the scene of death in our case is most probably attributable to this typical trait of self-inflicted abdominal wounds.

Furthermore, it is crucial to consider the medical and psychosocial background of the deceased to understand the intent of injury in such unique cases.^{26, 27} Significantly, depressive disorders, which are known for their unique effects of increasing impulsivity and emotional turmoil, are frequently associated with suicide. ²⁸ Depression increases the risk of suicide by cultivating feelings of hopelessness, which can be exacerbated by impulsivity, leading to sudden, premeditated suicide attempts. Impulsivity, characterized by a lack of self-control and careful decision-making, can result in actions driven by strong emotions without regard for the consequences. Consequently, those who are depressed and exhibit impulsive tendencies may struggle to effectively address problems and manage stress, increasing the likelihood of resorting to impulsive suicide methods to escape their problems.^{29, 30} Individuals with depression are five times more likely to attempt suicide than the general population. ³¹ Additionally, failing to adhere to antidepressant medication regimens is associated with impulsive suicide methods, primarily because it causes depressive symptoms to resurface, which can heighten suicidal thoughts and behaviors, diminish impulse control, and increase the chances of relapse and rehospitalization, potentially leading to more lethal suicide attempts.^{32, 33} The intricate relationship between depression and suicidal behavior calls for comprehensive prevention and intervention strategies that span multiple levels of care. This strategy involves the early detection of at-risk individuals, application of evidence-based therapeutic methods, use of pharmacological treatments, and implementation of crisis management protocols. Furthermore, it is essential to raise community awareness of the social factors influencing mental health and family education, enhance access to care, develop personalized treatment plans, and establish follow-up procedures along with innovative techniques to promote adherence among high-risk patients, all of which are vital elements of an all-encompassing suicide prevention framework.^34–36 Suicide disproportionately affects low- and middle-income countries, with men being three times more likely to be victims than women, particularly those in the young to middle-aged demographic.^{26, 37} Our study involved a middle-aged male victim with a history of depressive disorder characterized by poor adherence to antidepressant medication, which most likely contributed to the sequence of self-inflicted injuries observed. Consequently, stakeholders are advised to maintain effective suicide prevention strategies, particularly for patients with depressive disorders. This includes strict adherence to prescribed medical treatments, educating families, implementing psychosocial interventions, and ensuring consistent follow-up care, all of which are crucial for long-term stability and minimizing the risk of suicide.^{36, 38} This case report highlights the challenges in distinguishing complex suicides from homicides and accidents. Comprehensive and detailed autopsy findings are crucial for accurately determining the manner of death.^{39, 40} In this case, we used the patterns of the ligature mark and abdominal wounds, the medical background of the deceased, and crime scene examination findings to classify the case as a complex suicide who attempted to kill himself by stabbing his abdomen and finally ended his life by hanging.

Findings and Contributions

This case report details a rare suicide incident involving both hanging and self-inflicted abdominal wounds, contributing to the limited literature on complex suicide methods. This study highlights the difficulties in identifying complex suicides and the potential for misclassification, stressing the importance of a comprehensive postmortem examination that integrates autopsy findings, crime scene evidence, and the deceased’s medical history to accurately distinguish complex suicides from homicides or accidents, which will benefit experts involved in death investigations. Furthermore, it outlines the unique patterns of self-inflicted ligature marks and abdominal cuts, providing a valuable reference for forensic professionals in future investigations. The report also underscores the significant impact of depressive disorders, especially when medication is not followed, on increasing the likelihood of impulsive suicidal actions, which requires careful consideration in similar cases. These findings also highlight the need for improved management strategies for individuals with depressive disorders, including ensuring medication adherence and regular follow-up.

Conclusions

The history of depressive disorder with medication non-adherence and characteristic suicidal hanging and self-inflicted abdominal injuries, along with the absence of defensive or struggle injuries and negative toxicological results, were pivotal in classifying the case as a complex suicide. A thorough autopsy can pinpoint and rule out particular injuries and intoxication, while a meticulous examination of the crime scene can reveal evidence of staging or a struggle. Additionally, a thorough psychosocial history offers insight into whether the intent was suicidal or influenced by external pressures. Together, these elements provide crucial evidence for accurately identifying complex suicide cases. This triad forms a multidisciplinary strategy for reconstructing events, ensuring precision in cases where surface appearances, such as staged homicides, might otherwise be deceptive. Depressive disorders, particularly when accompanied by a lack of adherence to medications, significantly increase the risk of impulsive suicide methods, which is most likely to occur in this scenario, according to the evidence found.

This study contributes to the existing literature on complex suicides by emphasizing the value of conducting prompt and comprehensive postmortem forensic investigations and accurately analyzing the findings to ascertain the intent and origin of injuries. Additionally, this case report reinforces the need for increased awareness and improved management strategies for individuals with depressive disorders to minimize such serious outcomes. Further research using a sufficient number of participants to explore the factors and motivations behind different suicide methods is warranted to enhance forensic investigation practices and develop effective suicide-intervention strategies.