Suicide by exsanguination from a puncture wound to a haemodialysis arteriovenous fistula: a forensic case report with forensic implications.

Fatal haemorrhage from a haemodialysis vascular access site is an uncommon but well-recognized cause of death in forensic practice, most frequently associated with incised or sharp-force injuries. We report a case of suicide by exsanguination resulting from deliberate needle puncture of an arteriovenous fistula in a haemodialysis patient who was a healthcare professional. A comprehensive forensic investigation, including death scene investigation, medicolegal autopsy, toxicological analyses, and evaluation of the available circumstantial evidence, was performed. A 63-year-old female nurse with end-stage chronic kidney disease receiving maintenance haemodialysis was found dead in the bathroom of her home, surrounded by extensive pooled blood. A blood-stained needle was recovered at the scene, together with a handwritten farewell note. Autopsy revealed a fresh puncture wound within the vascular access scar overlying the haemodialysis arteriovenous fistula, with a corresponding defect of the fistula wall and surrounding haemorrhagic infiltration. Internal findings were consistent with fatal exsanguination, while toxicological analysis was negative. The integration of death scene findings, autopsy findings, and circumstantial evidence supported the determination of suicide. This case highlights the forensic importance of meticulous examination of haemodialysis vascular access sites and demonstrates that even a subtle puncture wound may result in fatal haemorrhage, emphasizing the need for comprehensive forensic assessment to distinguish intentional vascular access injury from accidental or iatrogenic haemorrhage.