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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
PubMed

Insights

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 pneumothorax

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