A planned complex suicide: need for a high index of suspicion

Unusual ways of committing suicide are reported in the medico-legal literature, but few refer to the so-called "planned complex suicide" (PCS). PCS, also termed primary combined suicide, is defined as the combination of two or more methods of injury by the suicidal person to prevent failure of a single method of suicide alone. In contrast, in secondary or unplanned complex suicide, the victim uses the second method of suicide only after failure of the first method.2 Combinations of shooting, hanging, burning, and/or poisoning have been used as suicidal methods. Sometimes the double use of one method such as simultaneous gunshot wound from two firearms or ingestion of two different toxic substances has been reported. This gives the suicidal person a high degree of protection against failure of one of the methods, as both modes of injury are relatively certain. This case report demonstrates the importance of the treating physician maintaining a high index of suspicion for the possibility PCS with the aim of avoiding a misdiagnosis that may be fatal.