Kirsty Cotton and her husband, Trevor Gooden, are driving in a car, when suddenly Trevor nearly hits another car and crashes over the edge of a bridge into the river. Trevor escapes but Kirsty remains trapped inside.
Trevor wakes up in the hospital, suffering from headaches and amnesia. Kirsty is said to be missing, and her door in the car was open despite the fact that Trevor claimed it was locked. Trevor has nightmares about a surgeon performing painful surgery on him. He watches a tape and sees that he gave the Lament Configuration to Kirsty as an anniversary present.
Trevor is in love with his boss, Gwen. But at one point, he has a nightmare where a camera that is recording the room shows (though this is not happening in the room) two Cenobites killing Gwen. Trevor is also in love with two other women named Tawny and Sage, and he has a nightmare where he finds Tawny lying dead in a chair. Pinhead appears and gives him a note saying "All your problems are solved", and the body is gone when next he enters, before he wakes up. When next he sees Tawny, she doesn't remember being with him at all, and is with another man.
Trevor soon realizes that Dr. Allison, whom he is talking to, is really a hallucination, when the janitor doesn't see her.
It soon becomes apparent that Trevor was not a good man, and was conspiring with his friend Bret to kill Kirsty for her inheritance of Larry and Frank's money. Gwen is said to be dead, and Trevor is suspected for the murders. Only Detective Lange believes he is innocent. Later, Trevor has a nightmare about Bret getting angry at him because their plan was to kill Kirsty and make it look like a suicide, but instead he drove the car into the river to drown her. Bret shoots himself before Trevor wakes up. Later, he has another nightmare about Sage trying to kill him, and when awake he finds her dead, stabbed in the head.
Detective Lange enters the room and tells Trevor that it is not his lucky day, because a body was found in the river and Lange takes him to the morgue to see, in the process revealing that he and Detective Givens are the same person, created by Pinhead. Trevor enters the morgue and sees a dead body with a sheet over it. He is about to remove the sheet when Pinhead traps him with hooked chains and shows what really happened. When Trevor made Kirsty solve the Lament Configuration so Pinhead would kill her, finding Trevor bland compared to one who escaped him before, Kirsty offered him five souls in exchange for her own. She killed Gwen, Tawny, Sage, and Bret all by shooting them in the head, and Pinhead took their souls. Pinhead says that only four would not satisfy the deal, and reveals that in the car Kirsty shot Trevor in the head, which was what caused him to crash, and Kirsty was the one who survived. Trevor removes the sheet and finds his own body lying there, and realizes he was the fifth soul, and was in hell the entire time.
On Earth, after the car crash, Kirsty says Trevor shot himself, and he is believed to have killed the others when the bullets will be matched to the gun. Everyone from Trevor's hell exists in reality, including Allison and Lange, and the surgeon from his nightmares is really a coroner. The film ends with Kirsty walking away with the Lament Configuration.
- Dean Winters as Trevor Gooden
- William S. Taylor as Detective Mike Lange
- Michael Rogers as Detective Givens
- Doug Bradley as Pinhead / Merchant (as Doug Bradley/Charles Stead)
- Trevor White as Bret
- Rachel Hayward as Dr. Allison Dormeer
- Sarah-Jane Redmond as Gwen Stevens
- Ashley Laurence as Kirsty Cotton-Gooden
- Jody Thompson as Tawny
- Kaaren de Zilva as Sage
- Dale Wilson as Chief Surgeon / Surgeon Cenobite
- Ken Camroux as Dr. Ambrose
- Brenda McDonald as Angular Nurse
- This is the only film where Pinhead never directly kills anyone. (It is believed the Pillar of Souls was his means of hiding in Hellraiser II, and he killed the worker)
- This is also the only Hellraiser film to feature Ocean voice actors (as many horror movies do). Dale Wilson is the chief surgeon/coroner, and Alec Willows is the janitor.