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Fatal accidental oxygen insufflation via suprapubic catheter
Kunz Sn1, Baisch S2, Steinhoff Sl3
1Institute of Forensic Medicine, Ulm University, Prittwitzstr. 6, 89075, Ulm, Germany. sebastian.kunz@uniklinik-ulm.de.
Forensic Science, Medicine, and Pathology
|August 11, 2026
Summary
Medical tubing misconnections, though rare between oxygen and urinary catheters, can be fatal. This case shows how a rare misconnection caused death, emphasizing the need for safer medical device connectors.
Area of Science:
- Medical Device Safety
- Forensic Pathology
- Pulmonary Medicine
Background:
- Medical tubing misconnections pose significant risks in healthcare.
- Intravenous and enteral feeding misconnections are documented, but oxygen to urinary catheter misconnections are rare.
- Patients with chronic obstructive pulmonary disease (COPD) and cognitive impairment are vulnerable.
Purpose of the Study:
- To report a rare case of fatal medical tubing misconnection.
- To highlight the diagnostic utility of postmortem CT-scans in conjunction with autopsy.
- To emphasize the need for standardized, incompatible medical connectors.
Main Methods:
- Case report of a 65-year-old male with COPD and paralysis.
- Postmortem CT-scan and traditional autopsy.
- Analysis of barotrauma and gas distribution.
Main Results:
- Accidental connection of nasal cannula oxygen tubing to a suprapubic bladder catheter.
- Death attributed to acute respiratory failure from tension pneumothorax and pneumoperitoneum.
- CT-scan and autopsy confirmed barotrauma and gas distribution.
Conclusions:
- Standardized, incompatible connectors (e.g., ISO 80369) are crucial to prevent fatal misconnections.
- Postmortem imaging aids in diagnosing complex barotrauma.
- Vigilance is needed to prevent misconnections, especially in vulnerable patients.
Keywords:
Accidental deathBarotraumaForensic pathologyMedical tubing misconnectionPostmortem computed tomography (PMCT)Suprapubic catheterTension pneumothoraxMore Related Videos
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