The Seven Major Mistakes in Suicide Investigation

By Vernon J. Geberth, M.S., M.P.S.
Homicide and Forensic Consultant

©2013 Vernon J. Geberth, Practical Homicide Investigation
Originally published by Law & Order Magazine, Vol. 61 No. 1 January, 2013 pp 54-567

Under the title, "Seven Mistakes in Suicide Investigation
This PHI version of the Article has been Expanded for Research and Clarity.





Death investigation is a complicated process, which involves a number of different members of the police department as well as other forensic disciplines working together towards the goal of solving the case.







There may very well be miscommunications, which result in serious errors that affect the outcome of the case due to the various responsibilities uniform officers, detectives, medical examiners to forensic experts, prosecutors as well as others in the process.  This is especially true in the investigation of suicide.



Mistake#1  Assuming the Case is A Suicide Based on the Initial Report


If the case is reported as a “Suicide,” the police officers who respond as well as the investigators automatically tend to treat the call as a suicide.  It is a critical error in thinking to handle the call based on the initial report. The immediate problem is that psychologically one is assuming the death to be a suicide case, when in fact this is a basic death investigation, which could very well turn out to be a homicide.  The investigator cannot “assume” anything as a professional law enforcement officer.


Any preconceived theories or notions are dangerous in professional death investigation.  In addition to errors of assuming a “suicide” or natural death other preconceived notions may include deaths, which appear to be drug related and/or domestic violence.  One must keep an open mind and not be influenced either by the initial reports or the presentation in the crime scene. 


Case History


As a homicide commander, I recommended that a detective respond to every unattended death scene, whether it was reported as a homicide, suicide, accident or natural to assure that any potential crime scene and/or evidence surrounding the event was NOT disturbed. 


I recall responding to a reported suicide at a construction facility and arriving as the uniform officers were removing the victim’s wallet from his pants pocket as the body hung from an electrical appliance with a cord.  I asked them what they were doing and they replied that they were getting his identification so they could write up The Suicide Report.  I asked them how they knew it was a suicide.  They told me they got the call of a “Suicide” and when they arrived they saw the man hanging by his neck and assumed he had hung himself.


I advised the two officers that they were not in a position to “assume” anything and that a request for detectives to respond in fact meant that this was a crime scene.  The following is the protocol for the initiation of an effective crime scene investigation.


1.         Rapid response to the homicide crime scene by patrol officers. This is imperative in order to protect evidentiary materials before they are destroyed, altered, or lost.

2.         Anything and everything should be considered as evidence. Whether this evidence is physical or testimonial, it must be preserved, noted, and brought to the attention of the investigators. The only evidence collected at this point of the investigation is eyewitness accounts or spontaneous statements of a suspect at the scene.

3.         After the scene is secured, immediate and appropriate notification must be made to the homicide investigators.

New Photo #1 Redone.jpg










My preliminary observations indicated that the “Suicide” was actually a homicide and that someone had effectively staged the scene to make it appear to be a suicide.  I saw a piece of vegetation caught in the man’s hair that did not come from the location.  I also noticed dirt on his pants, which later analysis revealed that it did not come from the area.  The man had been strangled to death at another outdoor location and then transported to the construction site where he was “strung-up” with the electrical cord to make it appear to be a suicide.  The initial responding officers as well as the ambulance crew at the scene were ready to declare the death a suicide and were preparing to transport the body to the morgue.


Mistake#2  Assuming “The Suicide Position” At the Crime Scene

It has been my experience that when police officers or detectives hear the word “Suicide” they go into what I describe as the “Suicide Position.”  Suicides are non-amenable offenses that are not recorded in the UCR and therefore are considered less important than other events.


Without a doubt investigators take “short-cuts” when they hear the word suicide.  I have reviewed many suicide cases where it was apparent that the investigators did not take each point to its ultimate conclusion.  Sufficient photographs were not taken and certain tests were not conducted.  In some instances the deaths were suicides, but the incomplete and insufficient preliminary investigation raised legitimate concerns.


Death investigations of the elderly are oftentimes assumed to be naturals and there is a tendency on the part of uniforms and detectives to rush-through the crime scene process.   Many investigators, who have “bought-into” the initial call and treated the case like a routine suicide or a natural death, have been greatly embarrassed when the medical examiner’s finding showed the death to be a homicide.  They then find themselves in the unenviable position of having to explain how they missed crucial evidence or failed to take important crimes scene photos. 


Case History

A Sheriff’s Department was called to respond to a suicide in a residence.  The responding Deputy asked the husband what had transpired.  The husband told the Deputy that he and his wife were having some marital problems and that they were in the process of separating and that his wife was thinking about committing suicide.  Based on what the husband told him the Deputy stated the in his report: "It appears that the deceased was despondent over her marriage and had threatened to commit suicide.  She went into the bathroom closet and put a pillow over her head and appeared to have shot herself in the head area."


The reference to her threatening to commit suicide and her alleged despondency was not supported or corroborated by anyone who was interviewed except the husband, who reported that his wife committed suicide.  Furthermore, the reference to her putting a pillow over her head and shooting herself is purely speculative and was not based on any crime scene reconstruction or evaluation of the evidence present in the scene. When the First deputy notified the detective he told him that the case was a suicideand that the victim had been upset the last few days because of marital problems according to her husband.


It was apparent that the detective bought into the “Suicide Theory” based on the First Officer’s information.  My review of this case indicated that the investigator was just “Going-through-the-motions” of an investigation.  The detective did not properly document the crime scene.  He removed the gun before it was photographed and disturbed the original crime scene. The detective’s report did not contain any independent observations. The detective did not conduct any interviews of the victim’s family or friends nor did he look into the victimology.


The detective basically repeated what the First Officer told him and then constructed an expedient conclusion.  He classified the case as a Suicide. A coroner’s inquest later ruled that the death was a Homicide.


Mistake#3 Not Handling “The Suicide” as a Homicide Investigation   

According to Practical Homicide Investigation®, “All death inquiries should be conducted as homicide investigations until the facts prove differently. The resolution of the mode of death as Suicide is based on a series of factors which eliminate Homicide, Accident and Natural Causes of death.


I recommend that an investigator be assigned to every unattended death case.  Some agencies have mistakenly allowed patrol officers to conduct basic death investigations with the assumption that such deaths are generally not criminal incidents and don’t require detective investigation.  On the contrary, these cases may very well be homicides, which have been staged to appear to be suicide, accidents or natural causes. In equivocal death investigations there is the potential for major errors. If in fact, the death is later attributed to be homicide valuable evidence will have been lost or contaminated because the scene was not handled as a homicide case.  The critical interviews and interrogations as well as crime scene documentation and photographs are irretrievable.


Currently, with all the forensic programming available to the general public, which focuses on police procedure and forensic medicine, many people have come to believe that they are well versed and knowledgeable to the point that we have the “CSI Effect.”


The C.S.I. Effect refers to the phenomenon of the impact that crime scene and forensic criminal investigation television shows on the general public.  The fictional aspects of these programs provide the entertainment component.  However, there are a number of legitimate investigative techniques as well as tactical police procedures revealed to the viewing audience that contribute to the C.S.I. Effect.  The problem is that criminals read the same books and watch the same TV shows as everyone else and therefore gain insight into the investigative process as well as the value of trace evidence. 


It is not unlikely that someone who wanted to kill might “Stage-the-Scene” to make a death appear to be a suicide to cover up the murder.


Case History


An actress living in a New York City apartment was discovered hanging by her neck from the shower curtain rod in her bathroom.  The case was reported as a suicide by the person discovering her body and the initial police officers had reported the case as a suicide when they notified detectives to respond.   When the detectives arrived they examined the room and the body of the victim and observed an ante-mortem injury to her face and noticed a Reebok® sneaker print on the edge of the tub and the toilet seat.  The woman was barefooted and could not have caused that impression.  The Crime Scene Detectives lifted the footwear impression as a piece of evidence as the detectives conducted their canvass of the apartment and questioned the victim’s relatives and friends.  Basically, they determined that the victim did not fit any “suicide profile” and the death was in fact suspicious. 


Detectives learned that a 19-year old Ecuadorian construction laborer who had been working in the adjoining apartment had gotten into a verbal dispute with the victim over the noise that he was making and angry words had been exchanged earlier that same day.  The construction worker had left the apartment shortly thereafter and failed to notify his foreman.  When the detectives located him at a friend’s residence he admitted that he had killed the woman by strangling her and then cleverly “staged” the scene by hanging her from the shower curtain rod top making it appear that she had committed suicide.  In order for him to lift her into that position he had to stand on the edge of the tub and toilet seat thereby leaving several footwear impressions, which matched his Reebok® sneakers.



Mistake#4 Failure to Conduct Victimology

One of the most significant factors to consider in any death investigation is victimology.  Victimology as it pertains to both suicide and homicide investigations is significant in ascertaining motives, suspects and risk factors.  In suicide cases, this becomes paramount in determining Motive and Intent.  Does the victim fit a “Suicide Profile?” Was there any evidence of marked depression or suicide ideations?  Did the victim have both short and long term plans?


Victimology is the collection and assessment of all significant information as it relates to the victim and his or her lifestyle.  Personality, employment, education, friends, habits, hobbies, marital status, relationships, dating history, sexuality, reputation, criminal record, history of alcohol or drugs, physical condition and neighborhood of residence are all pieces of the mosaic that comprise victimology.   The bottom line is “Who was the victim and what was going on in his or her life at the time of the event.”  The best sources of information will be friends, family, associates and neighbors and that will be the initial focus of the investigation.



Mistake#5 Failure to Apply the Three Basic Investigative Considerations To Establish if the Death is Suicidal in Nature


The investigator should be aware of three basic considerations to establish if a death is suicidal in nature.

1.  The presence of the weapon or means of death at the scene.

2.   Injuries or wounds that are obviously self-inflicted, or could have been inflicted by the deceased.


3.  The existence of a motive or intent on the part of the victim to take his or her own life.



The Weapon


The weapon or means of death should be present in cases of suicide. However, the absence of a weapon does not necessarily indicate that death was due to a homicide. The weapon could have been stolen or otherwise disposed of prior to the arrival of the authorities (as seen in the case of the heirloom handgun). Furthermore, family members have been known to conceal weapons and/or suicide notes in order to collect on an insurance policy.




Injuries and wounds in suicides may be very similar to those observed in homicides. However, certain observations that the wounds found on the body are consistent with homicide or suicide should be made. For example, a person found dead from multiple stab wounds of the back would certainly not be considered a victim of suicide. Likewise, in suicide cases, there appear to be preferences and avoidances for certain parts of the body.  The investigator should have an appreciation for the lethality of wounds.   Remember: It’s not the number of wounds that are self-inflicted, but the lethality of these wounds and what particular organs have been impacted.


         Could the deceased cause the injuries and death?               

         Was the person physically able to accomplish the act?

         Are the wounds within the reach of the deceased?

         Are the wounds grouped together?

         Is there more than one cause of death?

         Are there any hesitation marks or wounds?

         Describe the nature and position of the injuries.

Motive or Intent


The manner of death may be important in determining suicidal intent.  People who hang themselves or jump to their deaths certainly have indicated an intention to take their lives.   Similarly, deaths that involve a combination of methods, such as poisoning, shooting, slashing of wrists, inhaling gas, etc. show an extreme desire to die.


         Obtain Background Information  ( Medical & Social )

         Were there any Warning Signs?

         Were there any recent deaths in the family?

         Any indication of recent upset or stress?

         Did the victim leave a suicide note?

         Has deceased been under professional treatment or counseling?

         Had the deceased ever attempted suicide in the past?

         Has anyone in family ever committed suicide?



Mistake#6 Failure to Properly Document any Suicide Notes


If the victim left a note, and even if you are sure that the case is a suicide, obtain an exemplar (An example of the victim’s handwriting from some document that was known to have been written by the deceased.)  This is necessary especially when later on there is a dispute over the classification of the death as a suicide.


The presence of a Suicide Note certainly suggests suicide.  However, there are a number of investigative considerations to determine whether or not the note is genuine.


         Was it written by the deceased?

         Was it written voluntarily?

         Does the note indicate suicidal intent?


Suicide notes oftentimes have mixed emotional content including “positive” and “negative” feelings. Suicide ideations, which are the formation and conception of ideas in the mind of the deceased, present suicide as a viable option.  There may be reference to an “afterlife” or being with a loved one “looking down”, etc.  The Suicide Note is a direct communication indicating intent to commit suicide. The letters and notes may be addressed to relatives and friends or left at the death scene, which indicate severe depression and or anger.  The notes are often coherent and legible unless written under the influence of alcohol or drugs and may be instructional and/or admonishing.  These notes should be collected in a manner to preserve any latent fingerprints and exemplars should be obtained for comparison.  The note oftentimes provides a basis of inquiry into the background of the deceased.



Mistake#7 Failure to Take Each Factor to its Ultimate Conclusion


In order to conduct an efficient and effective investigation, the detective first concentrates on the mechanical aspects of the death, i.e. motives and methods, wound structures, crime scene reconstruction, bloodstain pattern analysis, the cause, manner and time of death as well as other factors that provide clues to the dynamics of the event.  The detective then accesses various sources, which can be applied to his or her investigation.  In suicide cases the application of a “Psychological Autopsy” might be useful in drawing conclusions but only if the information obtained for this instrument is taken concurrent with the event and not after people have formulated an opinion.


“Remember, Do It Right The First Time.  You Only Get One Chance.”

Quote from Lt. Cmdr. Vernon J. Geberth,

From 1980 in Law & Order Magazine




It should be noted that the final determination of suicide is made by the medical examiner/coroner after all the facts are evaluated. However, the investigation at the scene and an inquiry into the back­ground of the deceased may indicate the presence of life threatening behavior or activities that suggest suicidal intent. Of course, the medical examiner/coroner is supposed to avail him or her of the input of the investigators, who were present at the scene and conducted the death investigation.


These copyrighted materials have been excerpted with permission from Geberth’s textbook, Practical Homicide Investigation: Tactics, Procedures, and Forensic Techniques 4th EditionCRC Press, LLC 2006.