The paper presents a case of medical malpractice during the test for phenylketonuria. The authors analyzed all documents collected in the course of the investigation of infant poisoning due to accidental administration of ninhydrin. The medical assessment was based on an extensive review of the case history, as well as on spectroscopy (FT-IR), chromatography and chemical analysis findings that allowed for confirming the presence of the toxic substance in the evidence material collected during the initial investigation. The obtained results confirmed the presence of ninhydrin in the tea cup and in the teaspoon, which were used to prepare the diagnostic medium. No ninhydrin was found in other investigated materials. The employment of routine research methods, including GC-MS, FT-IR and UV-VIS, allowed for detection and identification of the pure chemical form of ninhydrin, as well as its color complex with amino acids. The detailed case analysis, as well as the variability of extensive evidence material collected during the investigation allowed for determining the identity of persons responsible for accidental administration of the poisoning substance to the infant.

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