Introduction

Psilocybin is a hallucinogen found in more than 200 species of basidiomycetes fungi, commonly known as “magic mushrooms,” which are distributed worldwide and subject to legal restrictions due to recreational usage. 1 Although it exhibits low toxicity, it mediates significant changes in perception, mood and cognition through agonism with the 5-HT2A receptor.2–4 It has gained increased attention for its potential application in the treatment of psychiatric disorders including treatment-resistant depression, anxiety, substance use disorder, and obsessive-compulsive disorder. 5 However, a systematic review revealed that the association between suicidality and psychedelic use in both clinical and recreational settings is mixed. 6

Challenging effects associated with psilocybin use include “bad trips” that present with a risk of physical harm, enduring psychological symptoms and attempted suicide. 7 Previous reports of suicide under the influence of psilocybin are rare and include self-inflicted wounds and falls from a height.8–11 Importantly, completed self-harming and self-harming attempts have been described in individuals without a prior psychiatric history.9,12

Suicides are classified as simple when only one method of self-harming is employed, or complex when more than one self-harming method is utilized. Complex suicides are uncommon occurrences in forensic pathology and are estimated to represent 1.5–5% of all completed suicides. 13 To the best of our knowledge, there is no previously published case of complex fatal self-harming under the influence of psilocybin.

We report the first case of complex fatal self-harm in the setting of psilocybin ingestion to highlight the potential for a varied presentation of fatal self-inflicted injury under the influence of psilocybin compared to previous reports. The absence of a history of suicidality in the decedent underscores the risk of fatal self-harm associated with psilocybin use and the challenge to appropriately certify the manner of death when a demonstrated intent to fatally self-harm cannot be established.