Fistula formation between trachea and the innominate artery is a life-threatening complication of tracheostomy. The overall incidence of tracheo-innominate artery fistula (TIF) has been reported to be 0.3- 0.7%. Several such cases occur in the first three weeks after tracheostomy and its hallmark is massive arterial bleeding either through or around the tracheostomy site. Mechanisms of fistula formation include mucosal necrosis due to pressure exerted by the cuff of the tracheostomy tube, high-cuff pressure, abnormally high innominate artery, low-placed tracheostomy (4 tracheal ring or below) and excessive head movement. Immediate surgical attention is the key to managing this fatal complication. We present herein patient who developed TIF and died as a consequence of massive haemorrhage into the tracheobronchial tree and asphyxia. It is a rare case and to our knowledge no case of TIF or any case series concerning this rare complication has recently been reported from Pakistan.