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.
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