Corrosion and fracture of a silver tracheostomy tube

A sterling silver tracheostomy tube broke in use resulting in the death of a child. The nature of the fracture in the brazed joint is described, and corrosion identified as the mechanism of degradation of the joint. The corrosion is due either to exposure to body fluids over a long period, or to the use of hypochlorite solutions for cleaning and disinfection. The silver braze used had inferior corrosion resistance. It is recommended that appropriate grades of silver brazing alloy be used in the future, and that the mechanical integrity of medical devices joined with silver braze be regularly checked to anticipate failure in use.