Plastic bag suffocation and codeine overdose: An unusual case of complex suicide and review of the literature

The term "planned complex suicide" refers to cases where two or more suicide methods are applied simultaneously. Plastic bag suffocation is a suicidal method commonly combined with self-poisoning by inhalation of volatile compounds or pharmacological substances at poisoning dosage. A 67-year-old woman was found dead on the couch. The head was wrapped in a plastic bag knotted at the front of the neck. No signs of struggle were present on the scene. In the fireplace, there were two blisters of acetaminophen/codeine phosphate tablets. Postmortem examination showed congestion of the face and the neck and pulmonary edema with patchy emphysema. There was no evidence of physical duress. Toxic levels of codeine were detected in the blood. The death was related to a complex suicide involving codeine overdose and asphyxia by plastic bag suffocation. The hypoxic/cardioinhibitory effects of plastic bag suffocation combined to codeine-induced deep reduction of respiratory rate, making the suicide hypothesis the more likely scenario. In order to assess what elements contribute to postmortem diagnosis in complex suicides with plastic bag suffocation, a review of the forensic literature published between 2002 and 2022 was performed. This article emphasizes the complexity of diagnosing deaths involving plastic bag suffocation in suicides, particularly when combined with other methods like inert gas inhalation or drug intake. It underscores the importance of comprehensive toxicological analyses, careful scene examination, and histological studies, not forgetting a thorough comparative analysis of the existing literature, to accurately determine the cause and manner of death in such cases.