Fatal accidental oxygen insufflation via suprapubic catheter.

Abstract

Medical tubing misconnections represent a severe and often underreported hazard in clinical and home-care settings. While intravenous and enteral feeding misconnections are well-documented, accidental connections between oxygen delivery systems and urinary catheters are exceedingly rare. We present an unusual forensic case of a 65-year-old male with chronic obstructive pulmonary disease (COPD) and lower-body paralysis who accidentally connected his nasal cannula oxygen tubing to his suprapubic bladder catheter following a fall from his bed. The cause of death was determined to be acute respiratory failure secondary to barotrauma-induced tension pneumothorax and tension pneumoperitoneum, exacerbated by pre-existing pulmonary compromise. This case highlights the vital role of combining postmortem CT-scan with traditional autopsy to accurately diagnose complex barotrauma and gas distribution. Furthermore, it underscores the urgent need for standardized, incompatible connector designs (such as the ISO 80369 standards) to prevent fatal mechanical misconnections, especially in patients susceptible to hypoxia-induced cognitive impairment.