Inadvertent passage of a tracheostomy tube through Murphy's eye during percutaneous tracheostomy tube insertion

Summary Percutaneous tracheostomies are commonly performed at the bedside in Critical Care Units. The use of bronchoscopy during the procedure is variable. We describe a case of inadvertent cannulation of Murphy's eye with a tracheostomy which initially went unrecognised. Recommendations from the NCEPOD report “On the right Trach” related to the use of bronchoscopy during percutaneous tracheostomy insertion and awareness of the nuances of different endotracheal tubes may have prevented this complication.