Coroner's Finding: TILKA Susan Marie

52y · Female·haemorrhage from a tracheal-innominate artery fistula complicating a tracheostomy following cerebral infarction

A 52-year-old woman died from catastrophic haemorrhage due to a tracheal-innominate artery fistula 10 days after percutaneous tracheostomy following stroke and decompressive craniectomy. Minor bleeding was observed 3 days before death. The coroner found no shortcomings in treatment and concluded the death was not avoidable. Tracheoarterial fistula is extremely rare (0.7% incidence) and has no reliable diagnostic tests. While sentinel bleeding precedes catastrophic haemorrhage in 34-50% of cases, the observed bleeding (3mls) was ambiguous and could represent minor stoma bleeding rather than herald bleeding. Bronchoscopy, angiography, and other investigations would have low diagnostic yield. The coroner recommended enhanced staff education about bleeding as a potential warning sign and modification of tracheostomy management protocols and training workbooks.