Forensic Characterisation of Complex Suicides: A Literature Review

Complex suicides refer to using two or more suicide modes. In the literature, complex suicides are distinguished into planned and unplanned. Using multiple methods is related to ensuring a fatal result or because the first method appears too painful, time-consuming, or ineffective. The review aims to provide an overview of the critical features of complex suicides in the forensic context. The review was conducted by searching online databases (PubMed Central and Scopus) up to March 2023. We identified 52 articles that met the inclusion criteria, describing 261 cases. Suicides were classified as planned in 136 cases (52.1%); 105 cases (40.2%) were defined as unplanned, while in the remaining 20 cases (7.7%), the authors did not propose any classification. In 2/261 (0.8%) cases, four modes were indicated, three modes were observed in 34/261 cases (13%), and in 224/261 (85.8%) cases the suicides were carried out using a combination of two distinct methods. The method most frequently employed in the first instance in unplanned suicides were sharp-force injuries and stabbing, followed by mechanical asphyxia (hanging, self-strangulation, plastic bag suffocation) and a fall from height. Regarding planned suicide, the most frequent suicide methods were asphyxia, intoxication (drugs, substances of abuse, or alcohol), and poisoning via toxic substances. Complex suicides represent a relatively rare entity in forensic pathology; nevertheless, they can be challenging for the forensic pathologist in terms of differential diagnosis compared to homicides, due to the sometimes multifaceted presentation.