Exsanguination from an arteriovenous dialysis fistula: accident, suicide or medical malpractice?

A female senior dialysis patient was found dead in her apartment, covered in blood. Bloodstains were observed in different rooms of the apartment. During the post-mortem examination on site, a small, roundish opening of the skin was observed on the flexor side of the upper arm, within a longitudinal scar, from which blood was draining. Throughout police investigation, the possibility of an accident, a suicidal act, or medical malpractice during dialysis care was considered. An autopsy was ordered for further clarification. The autopsy identified exsanguination from a fistula on the flexor side of the left upper arm as the cause of death. The fistula could be traced into an arteriovenous shunt vessel that had been created a long time ago for dialysis. Upon projection onto the shunt vessel, punctiform crusts with underlying hemorrhages in the subcutaneous fatty tissue were identified in the skin. Histological examinations of the fistula and its surrounding tissue revealed no evidence of vasculitis or perivascular inflammatory changes, but puncture sites of varying ages with connective tissue texture disruption of the vessel wall and the adjacent subcutaneous tissue. Forensic medical examination concluded that death was caused by bleeding from an arteriovenous dialysis shunt vessel as a complication of hemodialysis. This case illustrates the relevance of comprehensive forensic medical case processing as the basis for a well-founded assessment.