International Journal of Legal Medicine

https://doi.org/10.1007/s00414-019-02085-2

CASE REPORT

A case of suicide by double gunshot wounds to the head: the ability

to act after the first shot
F. Maghin 1 & A. Antonietti 1 & D. Farina 2 & P. Benedetti 3 & A. Verzeletti 1

Received: 28 January 2019 / Accepted: 22 May 2019

# Springer-Verlag GmbH Germany, part of Springer Nature 2019

Abstract
A single gunshot (or multiple) does (do) not necessarily lead to immediate loss of consciousness or rapid neurological deficits, so the
victim may be able to repeatedly pull the trigger before achieving the lethal effect. Despite multiple gunshot wounds can lead to the
suspicious participation of other person to the death of the victim, in the medico-legal literature suicides with multiple gunshot wounds
are reported, demonstrating the ability of the victim to act after two or more gunshots. In this case, a 47-years-old man was found dead
in a pool of blood in the kitchen of his house. According to findings and analysis, the victim modified a single-shot, pneumatic toy gun
branded “Condor” Cal. 7 mm (a gun that is made mainly with “ZAMAK” zinc-based alloy, designed to shoot one soft-polymer bullet
at a time, with an initial kinetic energy lower than 1 Joule) into an improvised firearm weapon. With this gun, the victim achieved
shooting of two bullets into his head, both entering from the right temporal region of his head, with one stopped in the left occipital lobe
and the other one in the left temporal lobe. His death was caused by cranium-meningo-encephalic gunshot wounds. The conditions
supporting the hypothesis that the victim was able to fire two shots to his head before the onset of incapacitation (the type of bullets
used, the location of injuries and their consequences) and the characteristics that typically allow to distinguish the manner of death
(suicide vs homicide) were evaluated. Based on all the collected elements, it was possible to confirm that suicide was the manner of
death. This case underlines the importance of evaluating all available elements (post-mortem imaging, autopsy and toxicological
findings, ballistics and neuropathological evaluations) to distinguish suicide from homicide and to prevent incorrect conclusions.

Keywords Forensic science . Multiple gunshot wounds . Suicide . Ability to act . Incapacitation

Introduction Based on these facts, some victims may be able to repeatedly

Gunshot wounds to the head are rapidly fatal and have mor-
tality rate above 90% [1]. However, in the interval between the
shot injury and death, some victims are able to perform some
activities, such as walking or talking [2]. Consequently, single
gunshot (or multiple) does (do) not necessarily lead to imme-
diate loss of consciousness or rapid neurological deficits.
* A. Verzeletti
andrea.verzeletti@unibs.it
1
Forensic Medicine Unit, Department of Medical and Surgical
Specialties, Radiological Sciences and Public Health, University of
Brescia, Brescia, Italy
2
Radiology Unit, Department of Medical and Surgical Specialties,
Radiological Sciences and Public Health, University of Brescia,
Brescia, Italy
3
Industrial Engineer in Mechanics, Forensic Ballistic Expert,
Brescia, Italy
pull the trigger before achieving the lethal effect [3–5].
A single gunshot wound located in vital parts of the body is
common in a suicide event [6, 7], such as the head (81% of self-
inflicted gunshot wounds [5, 8, 9]). Multiple gunshot wounds, on
the other hand, can raise the suspicion of homicide, and in most
cases further investigations may be required [10]. However, sev-
eral suicides have been reported with multiple gunshot wounds
(in some studies about 1–7% of cases) [11–16], demonstrating
the ability of the victim to act after two or more gunshot wounds.
We report a case of two gunshots to the head, with special
focus on victim’s ability to act after the first shot.
The case
A 47-year-old man, a technician missing for about 2 days, was
found dead on the floor of his kitchen, with the head surrounded
by abundant amounts of blood. The doctor certified the death and

Fig. 1 Left, pneumatic gun Condor cal. 7 mm. Right, soft-polymer cal. 7-mm bullets box
highlighted a small wound to the head similar to an entrance
wound, in the absence of an exit wound. Next to the body, on
his left, the Police found a single-shot, pneumatic toy gun brand-
ed BCondor^ cal. 7 mm, designed to shoot one soft-polymer
bullet at a time, finding it to have been tampered to work as an
improvised firearm (Fig. 1). No evidence of violence or struggle
was detected from the initial external examination of the body. A
suicide note was not found. There were no signs of forced entry
at the front door and windows.
One year before, the victim expressed intention to commit
suicide (through a letter), which was justified by financial crisis
and precarious health conditions (pain in an operated elbow),
with subsequent hospitalization in a psychiatric hospital.
Fig. 2 CT findings (see text for details)
Int J Legal Med
Radiological examination
Before the autopsy, a computerized tomography (CT) of the head
(Fig. 2) was performed to detect the presence of bullets in the
cranium. In the squama of the right temporal bone, two oval bony
defects (Fig. 2a and b) of equal size were seen, with small bone
particles inwardly displaced around the fracture site; findings
were consistent with a double-entry point. A huge bone fragment
(Fig. 2, black arrow) was projected from the most posterior frac-
ture site towards the frontal horn of the right lateral ventricle. No
fractures corresponding to exit points were observed, and the two
bullets were retained in the left occipital lobe (Fig. 2, white ar-
rowhead) and in the left temporal lobe (Fig. 2, black
arrowheads), respectively. Intraparenchymal hemorrhage along
Int J Legal Med

Fig. 3 The two entrance gunshot

wounds (a and b) in the skin of the
right temporal region

b
a

the track of both bullets (Fig. 2, white arrows) and soft tissue
hemorrhage in the suprazygomatic compartment of the mastica-
tor space (Fig. 2, asterisk) were also observed.
Autoptic examination
The autopsy showed two entrance gunshot wounds in the right
temporal region. The first entrance wound (Fig. 3a) was a 4-mm
round skin defect, and around the wound there was soot depo-
sition. The bullet crossed the right temporal muscle, the squama
of the right temporal bone (oval-shaped defect, with flared mar-
gins inward, size about 1 × 0.7 cm (Fig. 4a)), the dura mater,
penetrated the right temporal lobe, crossed the brain, and
stopped in the left occipital lobe, where the bullet (cal. 7 mm)
was found. The wound track ran from right to left, from forward
to backward, and slightly from top to bottom.
The second entrance wound (Fig. 3b), located about 3 cm at
the front of the first one, was a 4-mm round skin defect, and
around the wound there was soot deposition. The bullet crossed
the right temporal muscle, the cranial bone in the right temporal
region (irregular oval-shaped defect, size about 1 × 0.7 cm, with
some small bony fragments attached to the margins, non-
removable but moving inward (Fig. 4b)), the dura mater, pen-
etrated the lateral surface of the right frontal lobe, crossed the

Fig. 4 The two entrance gunshot

wounds (a and b) in the cranial
bone of the right temporal region

b
a

Fig. 5 The regular defect of the
encephalic parenchyma from
which one of the bullets protruded
brain, and emerging and interrupting about 2 cm behind the
temporal pole, where there was a regular defect of the
encephalic parenchyma, from which a bullet (cal. 7 mm) pro-
truded (Fig. 5). The wound track ran from right to left, slightly
from forward to backward, and slightly from top to bottom.
In the context of the right temporal muscle, in correspon-
dence of the two paths, two small plastic fragments of conical
shape were found, probably belonging to the two bullets found
into the brain. The characteristics of the two entrance wounds,
found in the right temporal region, are both the consequence of
single-bullet wounds, fired in contact or near contact (i.e., at a
distance of less than 5 cm). In fact, there were the typical signs
left by gases and powders leaked from the trigger hole, from the
Fig. 6 Burn and tattoo halos
visible at the back of the left hand
Int J Legal Med
rupture of the casing, and from an uneven fissure in the barrel,
such as burn and tattoo halos, visible even at the back of the left
hand (Fig. 6).
The results of toxicological analysis for alcohol and illicit
drugs were negative.
The cause of death was cranium-meningo-encephalic gun-
shot wounds.
Ballistics considerations
According to findings and analyses, the victim modified a
single-shot, pneumatic toy gun branded BCondor^ cal. 7 mm
(a gun that is made mainly with BZAMAK^ zinc-based alloy,
Int J Legal Med
Fig. 7 a Gun’s piston with the 3-mm-diameter screw working as a firing pin. b Gun barrel and a short-range training cartridge cal. 7.62 × 51 NATO. c
Bottom barrel surface; the rectangle delimits the slot created by metal machining to allow loading of one cal.7.62 × 51 NATO cartridge inside the barrel
designed to shoot one soft-polymer bullet at a time, with an
initial kinetic energy lower than 1 J) into an improvised fire-
arm weapon. The modification was performed as follows:
– a 3-mm-diameter screw was fastened at the piston top to
let it protrude out of the air nozzle and act as a firing pin
(Fig. 7a);
– inner dimensions of the barrel were altered with a drill.
This allowed loading of one cal. 7.62 × 51 NATO car-
tridge in it. This ammunition can develop a pressure
higher than 4000 bar and can be shot with automatic
and semi-automatic rifles equipped to NATO armies until
1980 (Fig. 7b). With these modifications, the barrel’s
thickness was reduced by removing much of the metal
along the bottom surface, making a slot 7 mm wide and
20 mm long, starting 35 mm from the end of the barrel
(Fig. 7c);
– the barrel length was reduced to 85 mm (Fig. 7b).
The victim shot two model 1975 short-range cartridges,
adopted by the Italian Army for shooting practice. They are
equipped with a bullet whose bottom side is a shaped brass
cylinder (its mean weight is 5.50 g, with a central pass-thru
hole of 2.5-mm diameter) and the top of it is a polymer ogive
of 0.22 g weight.
The bullet has a 810 m/s speed at 24-m distance, with a
kinetic energy of 1870 [J = N m] = 190.61 [kgf m] at the same
distance. These values are related to a shot made with a BM59
automatic rifle, with a 490-mm long cal. 7.62 NATO barrel.
In this case, the energy was no higher than 10 [kgf m]; that
means bullets were at a starting speed of about 190 [m/s], for
sure enough to cause injuries and wounds found on the vic-
tim’s skull. The fact that the bullet has traveled only 44 [mm]
inside a smoothbore barrel must be considered; furthermore, a
great amount of the cartridge gunpowder and shot gases went
out from the primer hole, from the bulge of the neck of the
case, from the breaking of the case, and from the non-regular
profile of the slot on the barrel.
The bullets found inside the skull were made of brass and
were found to have no deformations. Cases have shown shape
alterations from the original profile and primer fragmentation,
due to shot pressure; the cases have been shaped over the
chamber profile made by the victim, manufactured with a drill
tool. This operation completely removed metal from the bot-
tom of the barrel, creating a 20-mm-long and 7-mm-wide slot.
After shooting, cases shown rupture along the longitudinal
direction, 20 mm long and 7 mm wide starting from the top
of the case.
Discussion
Knowing the conditions supporting the hypothesis of lack of
immediate loss of consciousness following a gunshot to the
head is essential to determine the manner of death (homicide
or suicide) [2].
Voluntary physical activity requires that some structures of
the central nervous system (CNS) are intact, in particular parts
of the brain essential for cardiocirculatory and respiratory func-
tion (brainstem and diencephalon), motor paths (upper cervical
spinal cord, capsula interna, and radiatio thalami), and motor
areas (basal ganglia, cerebellum, motor cortex) [1, 5, 10, 17].

Lesions in one of these structures cause physiological in-
capacity to perform complex and long-lasting movements in-
dependent of consciousness and intention, excluding reflexes
and automatisms [1, 5, 18]. In other words, a cerebral concus-
sion is established, where the major symptoms are immediate
unconsciousness and loss of muscle tone [1].
Gunshot wounds with a trans-ventricular trajectory are a
serious complication, resulting in rapid loss of conscious-
ness and high mortality, mostly for blood tamponade of
the ventricular system. Furthermore, the walls of the ven-
tricles are made up of brain tissue of functional impor-
tance for both the state of consciousness and motor activ-
ity [15]. Oxygen stored in brain cells ensures a physical
activity of about 10 s, enough to pull the trigger at least
once again, even in those cases where there is a severe
intracranial hemorrhage [3, 4, 11–15].
Despite this, survival time and physical activity of victims
following fatal injury cannot be accurately predicted [19] and
an interval of unconsciousness can apparently occur between
shots in some cases [20].
Several cases of ability to act after one or more gunshots to
the head in suicide events have been described [2, 4–6, 10, 12,
14]. Adopting these case analyses as foundation, it was pos-
sible to identify the necessary conditions supporting the hy-
pothesis that the victim was able to fire two shots to the head
before the onset of incapacitation. In particular, the type of
bullets used, the location of injuries, and their consequences
are considered [15].
Regarding the type of bullets, gunshot wounds are caused
by either low-speed or high-speed bullets. Low-speed bullets
cause primary lesions of encephalic tissue in the absence of
significant lesions surrounding brain tissue, while high-speed
bullets cause destruction of tissues surrounding the path of the
bullet. The kinetic energy of the bullet causes a temporary
cavitation proportional to its speed (even up to 10–20 times
the size of the bullet), producing indirect damage by a sudden
increase of the intracranial pressure [1, 5, 14, 21]. Increased
Fig. 8 Fracture on two cases near
the slot shown in Fig. 7c
Int J Legal Med
intracranial pressure, resulting from the passage of the high-
speed bullet inside a confined space with inextensible walls,
causes secondary bone fractures, areas of cortical contusion,
and intracerebral bleeding in distant areas [1, 2].
Regarding the site of the lesions, when a bullet penetrates
into the skull, the Bability to act^ can be preserved for a while
when the lesion is located in the so-called mute areas of the
brain [5, 10, 20]. Injuries involving one or both frontal lobes
or lesions of a single temporal lobe do not cause loss of motor
abilities, due to the lack of vital centers or motor areas [5, 14,
15]. In addition to the direct damage of the bullet on critical
regions of the CNS, the Binability to act^ can also be caused
by the secondary effects of the bullet, such as intracranial
hypertension. The increase in intracranial pressure may be
due to the development of massive edema or bleeding after
the lesion [5].
In our case, the ballistics consultant has assessed the type of
bullet used by the victim (bullet cartridges Mod. 1975 Short
Range, cal. 7.62 × 51 NATO, for automatic and semi-
automatic rifles of the same caliber).
The barrel and the gun chamber were damaged by the
expanding powder gases. The kinetic energy of the bullets that
caused the victim’s death was low (probably less than
10 kgm), considering that the initial bullet speed was less than
190 m/s. This speed was certainly adequate to cause the cra-
nial lesions, but the thrust of the gas applied to the base of the
bullet was certainly very low (5.6%) compared with the thrust
of the gas produced by the combustion of the powder flakes
sealed in a cartridge fired by a standard automatic rifle. In fact,
most of the partially burnt powder flakes contained in the
cartridge and the gases produced by combustion were leaking
from the primary hole, from the rupture of the cartridge case
(Fig. 8) and from an uneven fissure on the bottom surface of
the front-side of the barrel. These residues have become a
deposit on the victim’s skin surface (right laterocervical re-
gion, shoulder, and right upper arm), determining the low
speed of the bullet.
Int J Legal Med
The bullets, especially the one used in the first shot, caused
lesions only to the parenchyma affected by their passage,
without extended cavitation or indirect damage due to sudden
increase in intracranial pressure, such as secondary cranial
fractures, areas of cortical contusion, and intracerebral hemor-
rhagic foci. This observation supports the hypothesis about the
lack of immediate incapacitation after the first shot, allowing
the victim to reload the gun to fire the second shot. The ability
to perform these operations suggests that no cerebral motor
areas or areas involved in maintaining the state of conscious-
ness or areas of vital importance were involved [5].
Moreover, it was possible to hypothesize the order of the
explosion of the bullets, considering the localization of the
lesions and the respective path. The brain CT may contribute
to the reconstruction of the paths of the bullets [21]. In our
case, the brain CT clearly showed the path of the bullet
through the brain as well as the compromised structures. The
first lesion resulted in a path that penetrated the right temporal
lobe and stopped in the left occipital lobe, while the second
lesion penetrated the right frontal lobe and stopped in the left
temporal lobe.
In a multiple-shot suicide, no more than one bullet can
involve in instantaneously lethal target, which must be con-
sidered the last wound inflicted [22]. Chronologically, the first
shot was the one located in the anterior part of the right tem-
poral region (Figs. 3b and 4b), which resulted in lesions in
non-vital regions for cardiocirculatory and respiratory func-
tion and non-essential regions for motor activity, such as the
antero-lateral portion of the right frontal lobe and those near
the apex of the left temporal pole. The second shot was the one
located in the posterior part of the right temporal region (Fig.
3a and Fig. 4a), which resulted in deeper lesions, affecting the
right temporal lobe and the left occipital lobe, and causing a
path into the brain from forward to backward and from the
right to the left.
Our hypothesis that between the first and second shot the
victim survived for a certain period of time and was able to
reload the weapon was confirmed by a ballistics consultant,
who determined that the operations could be performed in 20–
30 s, or even faster by the victim considering his knowledge of
the modifications of the weapon.
In fact, after shooting, the case could easily be removed by
introducing a 140-mm-long screwdriver (found nearby the
corpse) in the muzzle of the barrel, after tilting the barrel.
Considerations regarding the possibility of the absence of
immediate loss of consciousness as a result of the first gunshot
and the characteristics that typically allow to distinguish the
manner of death (suicide vs homicide) were integrated.
The Btypical^ entrance wound sites in suicides are located
in the temple, mouth, forehead, and left chest (82% of the
suicide cases), where vital organs guarantee an efficient and
rapid death. More often, entrance wound are contact or near
contact wounds (more than 97% of suicide cases) [6]. These
characteristics, identified on the victim’s body (wounds local-
ized to the temple, contact or near contact wounds, presence of
soot deposition around the wounds, abrasions, and areas of
tattooing on the right side of the face), do not exclude homi-
cide but are certainly typical for a suicide.
The deposition of powders on one hand makes it possible
to verify the hand that fired, or the hand used to stabilize the
muzzle and, therefore, indicative of suicide [9, 23, 24]. In our
case, on the back of the left hand, little and superficial exco-
riations, and tattooing, produced by the unburned gunpowder
were observed, suggesting that the weapon was held or
sustained even with the left hand (Fig. 6).
These assumptions are compatible with circumstantial data
considering that the victim could need to hold the weapon
with the left hand, while the right hand holding the left fore-
arm, because he was suffering for pain at an elbow (as
complained in the first suicide intent).
Moreover, toxicological analyses for alcohol and illicit
drugs were negative: the victim’s determination to commit
suicide was not influenced by substances able to modify his
ability to act [25].
Based on all the collected elements, it was possible to con-
firm that suicide was the manner of death.
Conclusions
Autopsies involving multiple gunshot wounds to the head
should be approached as homicide until proven otherwise
[5]. Suicide should not be excluded if the circumstantial data,
the clinical history, and the type of the weapon and the bullet
are suggestive. Once suicide can be listed as a possible manner
of death, particular attention should be paid to the location and
the characteristics of the brain lesions to determine a residual
ability to act after the first shot.
This case underlines the importance of evaluating all avail-
able elements, such as inspection, brain CT, necroscopic in-
vestigations, toxicological findings, and ballistics and neuro-
pathological evaluations, to distinguish suicide from homicide
and to prevent inappropriate conclusions.
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