Iatrogenic Burns of the Neckline in a Patient with Tetraparesis During Tracheotomy

J Forensic Sci. 2017 Jan;62(1):250-253. doi: 10.1111/1556-4029.13240. Epub 2016 Nov 10.


The paper presents a case of an atypical iatrogenic complication after tracheotomy analyzed on the basis of the case dossier materials submitted to the authors by the court of justice to prepare a forensic medical opinion concerning the correctness of the medical procedure. A 37-year-old woman was brought by the ambulance service to the hospital with acute respiratory failure due to post-tracheostomy tracheal stenosis. Tracheotomy was performed on an emergency basis. The patient suffered severe burns of the chest and neck. The experts concluded that the most probable cause of the incident was electrocautery-induced ignition of the disinfectant used for cleaning the skin before the surgery. It was established that with correct handling of the procedure, the aforementioned incident should not have taken place. Therefore, it cannot be regarded as a normal complication inherent in the risk associated with the procedure, but as a consequence of a medical error.

Keywords: burns; complications; electrocautery; forensic science; medical error; medical opinion; tracheotomy.

Publication types

  • Case Reports

MeSH terms

  • Adult
  • Anti-Infective Agents, Local / adverse effects*
  • Burns / etiology*
  • Electrocoagulation / adverse effects*
  • Emergencies
  • Female
  • Humans
  • Iatrogenic Disease*
  • Medical Errors / legislation & jurisprudence
  • Poland
  • Quadriplegia
  • Tracheal Stenosis / etiology
  • Tracheal Stenosis / surgery
  • Tracheostomy / adverse effects
  • Tracheotomy / adverse effects*


  • Anti-Infective Agents, Local