Abstract: On March 29, 2006, Employee #1 was sterilizing several instruments in a small tray of 2-glutaraldehyde at a general practitioner medical office. When the spill occurred, some of the disinfectant splashed into her mouth. Employee #1 went home, then admitted herself to the emergency room on April 2, 2006. Employee #1 remained hospitalized until her death at 8:08 a.m. on April 20, 2006. An autopsy was not conducted. A death certificated was issued on April 28, 2006, listing the cause of death as being from natural causes, with the immediate causes being bilateral multi-lobar pneumonia, diabetes, and coronary artery disease. However, the attending physician created another death certificate on May 23, 2006, that attributed the immediate cause of death to acute lung injury and toxic inhalation from the toxic spill of 2- glutaraldehyde.