Complex Fatal Self-Harm Under Psilocybin Intoxication: Suicidal Manner of Death or Not?

Psilocybin is a hallucinogen that causes significant changes in perception, mood, and cognition. Challenging effects include "bad trips" with the risk of physical harm, enduring psychological symptoms, and self-harming attempts. Previous reports of simple fatal self-harming with psilocybin ingestion have been described with methods that include self-inflicted wounds and self-initiated descent from a height. Complex fatal self-harming that employs more than one method is uncommon in forensic pathology and has not been previously associated with psilocybin use. A case of complex fatal self-harming following psilocybin ingestion in an individual with no history of suicidal ideation or attempts is reported. Findings at the scene and autopsy were consistent with self-inflicted incised wounds and plastic bag asphyxia-facilitated hanging in the context of use of magic mushrooms. The urine was positive for psilocin, the metabolite of psilocybin, and the quantification of psilocybin in the blood failed due to analytical issues. This case highlights the potential harm of psilocybin ingestion, the resultant complex pattern of fatal self-inflicted injury that can occur, and the challenge to certify suicide as the most appropriate manner of death when no pre-existent intent to fatally self-harm exists.