Original Article

Medico-Legal Journal
0(0) 1–5
Uncommon suicide methods in the ! The Author(s) 2021
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detention regime in Milan (1993–2019): sagepub.com/journals-permissions
DOI: 10.1177/0025817220986714
Forensic contribution on autopsy cases journals.sagepub.com/home/mlj

Guendalina Gentile, Stefano Tambuzzi, Michele Boracchi,

Paolo Bailo, Domenico Di Candia, Rachele Bianchi and
Riccardo Zoja

Abstract
We analysed the recorded cases of suicides committed other than by hanging in prison in Milan. A retrospective analysis
was conducted on 25,512 autopsies performed from 1993 to 2019, selecting all the suicides in prison but our attention
was focused solely on cases where an alternative mode to hanging was used. From a total of 97 suicide events in prison,
15 were consistent with the established search criteria: 6 victims died from plastic bag suffocation, 4 by direct inhalation
of butane gas, 2 associated plastic bag suffocation to inhalation of butane gas, one committed suicide with an edged
weapon, one by self-burning and, finally, one by voluntary ingestion of a food to which he was allergic, with the intent of
inducing an anaphylactic shock. Our analysis has shown that the landscape of prison suicides is diverse, not limited solely
to hanging. Therefore, it is necessary for the forensic scientific community to raise awareness of potentially unusual
suicide methods in prisons and, in the same way, for the Penitentiary Administration to put adequate preventive
measures and strategies in place.

Keywords
Suicide, uncommon suicide methods, detention regime, safety in prison, forensic pathology

Introduction investigations to ascertain what injuries were suffered

In Italy, suicides in prisons are increasing, and are 12
times higher than that in the general population.1 This
situation is made worse by intrinsic structural prob-
lems, the most common of which is overcrowding2
and long procedural delays.3
Suicides can, unfortunately, occur during the deten-
tion regime and are labelled as “critical events”.4
National5 and international6,7 standards guarantee
the right of detainees to be treated humanely and
require maintenance of an adequate level of attention
and surveillance.
Public health concerns inevitably arise regarding the
potential measures and strategies needed to reduce self-
harm. Prison staff may be suspected of misconduct,
prompting severe implications for the deceased’s
family, public opinion (high media interest), law
enforcement agencies and institutions. It is important
to determine whether there is any State liability8 and
carry out complex and accurate medico-legal
by the victim.9 It is universally known that most pris-
oners commit suicide by hanging.10 However, recently
forensic pathologists have had to deal with more
unusual means.
We retrospectively analysed all the prison suicides
between 1993 and 2019 other than those by mechanical
asphyxia from hanging. Our analysis aimed (1) to make
the forensic scientific community aware of these unusu-
al suicides in prisons and (2) to encourage the
Penitentiary Administration to ensure adequate pre-
ventive measures and strategies are in place.
1
Sezione di Medicina Legale e delle Assicurazioni, Dipartimento di
Scienze Biomediche per la Salute, Università degli Studi di Milano, Milano,
Italy
Corresponding author:
Riccardo Zoja, Sezione di Medicina Legale, Università degli Studi, Via Luigi
Mangiagalli, 37, 20133 Milano, Italy.
Email: riccardo.zoia@unimi.it
2 Medico-Legal Journal 0(0)
Materials and method
Procedure and analysis
We reviewed 25,512 autopsies performed in 27 years
(1993–2019) at the Institute of Forensic Medicine of
the University of Milan. From 4498 suicides, we
extrapolated those committed in detention focusing
solely on cases other than hanging mechanical asphyx-
ia. Victim data analysed were gender, age, medical his-
tory, drug use, cause of death, any previous suicidal
ideation and suicide attempts. The collected data
were analysed by calculating frequencies and
percentages.
Setting
Milan’s city has three prisons: the Bollate prison, the
Opera’s maximum-security prison, and the San Vittore
corrective centre. The Bollate prison houses a women’s
section and an advanced department for sex offenders
and receives those inmates already sentenced, redirect-
ing them to work and providing them with education
and cultural care programmes. Its capacity is 1251
people, with an average occupancy of 1142 inmates.
Opera’s maximum-security prison houses some High-
Security departments and a “section 41 bis” in which
the “hard prison” regime is in force. It can hold 918
people, with an average presence of over 1200 inmates.
The San Vittore accommodates individuals awaiting
trial or transferred to Milan for procedural rules; it
has a capacity of 745 people with an average occupancy
of over 800 inmates.
Ethical approval. All subjects enrolled in this study
underwent a judicial autopsy to clarify the cause of
Figure 1. Graphic representation of suicides events in prison from 1993 to 2019, with the detail of the ratio between hanging
mechanical asphyxia and other suicidal modalities.
death. Collection of health information and the sam-
pling and subsequent forensic analyses were, in all
cases, authorised by the investigating judge. Under
Italian law, these cases require no ethical authorisation
but the subjects’ anonymity must be guaranteed.
Results
Between 1993 and 2019 there were 97 prison suicides
(2.1% of all suicides equal to 0.4% of all autopsies): 82
were by hanging with 15 (15.4% of the total intra-
prison suicides) dying by other means (Figure 1).
Six were in Milan Opera Maximum Security Prison,
five in San Vittore and four in Bollate. Six inmates
suffocated themselves using a plastic bag secured
around their necks with shoelaces (plastic bag suffoca-
tion – PBS), four by inhaling butane gas, two from PBS
associated with inhalation of butane gas and one from
cuts to the left wrist. Two chose unusual methods: one
deliberately ingested a peach knowing he had a severe
allergy to self-induce an anaphylactic shock. The last
one set himself on fire using a lighter and sprinkled
alcohol over his body.
Victim analysis
Fourteen victims were Caucasian (10 Italians, 3
Romanians and 1 Tunisian); one was African
(Congolese), 12 were male and two female, with a
ratio of 4:1. The youngest was 21, the oldest 67. The
commonest age group was aged 20–29 (7) followed by
40–49 (5) and then 30–39 (2).
Analysis of health records showed that 9 out of 15
had at least one pre-existing condition: 6 were suffering
from one medical condition, i.e. depression (2 cases),
drug addiction (2 cases), high blood pressure (1 case) or
Gentile et al.
epilepsy (1 case); three were affected by several con-
comitant pathological conditions, i.e. depression and
multiple sclerosis (1 case), drug addiction and alcohol-
ism (1 case) and depression, drug addiction and alco-
holism (1 case). Most were being treated with
pharmacological therapies: anxiolytics (2 cases), anti-
depressants (1 case), antihypertensives (1 case), antie-
pileptics (1 case), or methadone via rehabilitation
programmes (4 cases). Four had manifested suicidal
ideation, and three had made earlier suicide attempts.
Autopsy analysis
All the victims underwent judicial autopsy within three
days of discovery. In all cases, the investigating judge
ordered histological and toxicological analysis for post-
mortem investigation. On external examination, all the
bodies were in a discrete state of nutrition and
conservation.
Cyanosis of the face and conjunctival petechiae were
documented in the victims who committed suicide
using PBS only, direct inhalation of butane gas, and
the combined use of plastic bags over the head and
inhalation of butane gas. Where the plastic bag was
secured with shoelaces around the neck, a characteristic
furrow and small skin abrasions were highlighted in the
neck area. These victims’ autopsy examinations showed
typical signs of death from asphyxia, such as very fluid
blood, plurivisceral congestion, petechiae and pulmo-
nary oedema. Histological investigations showed
microscopic findings consistent with the declared
cause of deaths: intra-alveolar oedema, foci of intersti-
tial and intra-alveolar haemorrhages, emphysematous
areas, focal atelectasis and alveolar macrophages. In all
cases, cause of death was identified with PBS or acute
butane intoxication.
In the suicide by self-burning, the victim set himself
on fire with a lighter after sprinkling his body with
alcohol. External examination revealed severe third-
degree burns on 95% of the body. Death resulted
from multi-organ failure after surviving for a week.
In one case the detainee had self-inflicted deep cuts
on his left wrist with a razor blade and died from hae-
morrhagic shock. External examination showed almost
absent hypostasis and diffuse pallor of the body. Four
continuous full-thickness skin injuries were observed
on the left wrist’s volar surface, with a major transver-
sal axis. The edges of the wounds appeared clean and
infiltrated with blood. Histological investigations
unequivocally demonstrated the vital reaction. The
left cubital vein’s complete transection was observed
on internal examination, and all viscera appeared
intensely pale.
In the unique case of death caused by an allergy of
which the victim was well aware, a hand-written
3
farewell note was found in his prison jumpsuit’s
pocket saying he intended to kill himself by eating
peaches as he knew he had a serious allergy to them.
External and internal examinations were not definitive
on the cause of death but histological investigations
were highly suggestive of anaphylactic shock as was
oedema of the glottis, intrapulmonary haemorrhages,
and mastocytes in the glottis, myocardium and both
lungs by immune-histochemical investigations (using
anti-tryptase serum and anti CD117 serum).
Forensic toxicological analysis
Chemical-toxicological investigations on all samples
taken during autopsy examination (femoral blood, car-
diac blood, urine, bile, gastric contents, brain, lungs,
liver and adipose tissue) were performed following the
Institute of Legal Medicine of Milan’s protocols. The
search for toxic volatile organic substrates was carried
out, including ethanol levels in plasma and assessment
of non-volatile organic toxicants to detect any pharma-
cologically active toxic substances.
High levels of alcohol in plasma were present in 2 of
the 15 victims (blood alcohol content between 1.7 and
2.5 g/L). In four other victims, there were therapeutic
levels of methadone. In two cases, benzodiazepines
(bromazepam, alprazolam) taken as anxiolytics were
present in addition to psychostimulants (caffeine,
cotinine and nicotine).
To detect aliphatic hydrocarbons (butane), the col-
lected samples (blood, brain, lung, liver and adipose
tissue) were immediately placed in previously calibrat-
ed 10 mL vials, sealed with Teflon and metal flange,
stored at –20 C until analysis. They were then ana-
lysed by gas chromatography (HS/GC) using an
Agilent 6890 and Agilent 5973 mass detector. Four
cases (the inmates who committed suicide by direct
inhalation of gas through cans) had high concentra-
tions. In the six cases with PBS and butane gas associ-
ation, the concentrations of this gas were high if not
peremptorily lethal.
Discussion
We analysed the 15 prison suicides in Milan committed
without self-hanging (15.4% of all the suicides).
Among these PBS, associated or not with the inhala-
tion of aliphatic hydrocarbons such as butane, was
most common. There was a single case of suicide
with a razor, a self-burning and a self-induced anaphy-
lactic reaction. A complete and detailed forensic
approach is essential to clarify the circumstances,8 the
means and cause of death in prison, to verify whether
the death was an unusual suicide rather than homicide,
accident or natural causes.11 To this end, in 2017, the
4 Medico-Legal Journal 0(0)
National Association of Medical Examiners (NOME)
developed recommendations to be followed by the
medical examiner investigating a death in prison to
ensure consistency and reliability of investigations.12
They state the most suitable procedures to be per-
formed, underlining all potentially useful investigations
in these cases: photographic surveys, radiographic
analysis, archiving and collection of evidence, histolog-
ical, toxicological and microbiological investigations
are often indispensable.
In the deaths from asphyxia (PBS, inhalation of
butane gas, PBS associated with inhalation of butane
gas), the forensic and toxicological investigations
enabled us to determine that death occurred by suffo-
cation due to the adherence of the plastic bag to the
breathing orifices associated or not with a toxic-anoxic
mechanism by replacing the alveolar oxygen with
butane gas. This gas has high toxicity and fat solubility.
It is rapidly distributed to the respiratory system and
the brain through the blood–brain barrier, causing
sudden death from cardiac arrhythmia, vagal inhibi-
tion, respiratory depression and anoxia.13 Suicides
resulting from just the direct inhalation of butane gas
are incredibly problematic diagnostically. So the results
of toxicological analyses are vital to diagnosis. In all
the cases of suicide by asphyxia, histological investiga-
tions were supportive and highlighted coherent micro-
scopic pictures of asphyxia in the lungs. In the more
unusual suicide cases, histological investigations also
provided a valid contribution, sometimes being decisive
particularly in the case of self-induced anaphylactic
shock where external and internal examinations did
not reveal anything relevant whereas the microscopic
immunohistochemical investigation did provide evident
markers of an anaphylactic reaction, such as the posi-
tivity to anti-tryptase and anti CD117 serum, as well as
widespread presence of mast cells.
Some inmates committed suicide in unusual ways; in
all cases, they applied lawfully owned objects in daily
use, such as plastic bags, shoelaces, alcohol, lighters,
razor blades, food and cans of butane gas. Although
these methods were unusual, most of them are consid-
ered not “risky” in prison, and there is no regulation on
the possession of them. Nonetheless, these examples
show that they can be lethal if misused. Awareness of
their potential to harm seems not yet sufficiently high
for them to be more regulated. In particular, we were
surprised that the unconventional tool most used here
was a butane gas cylinder for camping stoves which are
available to prisoners under the same Penitentiary
Administration, under the regulation referred to art.
13 of the DPR 30 June 2000 n. 230.14 Prisoners can
use personal stoves in their cell to heat liquids and
food already cooked and to prepare drinks and
foods after signing away liability by the Prison
Administration for its improper use. Therefore, it is
rare for prison staff to be accused of negligence
where cans are used for suicidal purposes.
Restrictions on the use of camping gas cooking stoves
in the cell can only be applied in exceptional situations.
They are also regarded as helpful to a prisoner’s re-
education, which is the ultimate aim of detention.
In Italy, the need to replace camping gas cooking
stoves with electric stoves is currently under discussion.
However, the cost of adapting cells to have electrical
connections that do not exist today and energy con-
sumption (per capita allocation) are key limiting fac-
tors. Further, these changes would lead to the failure of
the supplemental services, through which inmates can
buy food to cook in their cells. The financial loss for
Prison Administration is another inhibiting factor.
Even though valid alternative solutions exist, to date,
the Prison Administration is prioritising building new
jails to deal with prison overcrowding, rather than
spending money on the existing ones to make them
safer and pleasanter.
In conclusion, our analysis showed that the range of
prison suicides is diverse, not limited solely to
hanging, and the forensic scientific community needs
to be aware of the possibility of unusual suicides arising
while prison administrations should take adequate pre-
ventive measures and strategies to avoid these deaths
occurring.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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