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Aluminium phosphide is a highly lethal pesticide that liberates phosphine gas, leading to mitochondrial dysfunction, distributive shock and cardiotoxicity, but guidance on late pulmonary complications is limited. We report a previously healthy adolescent who ingested ~1.5 g of aluminium phosphide in a suicide attempt and initially presented haemodynamically stable with metabolic acidosis and elevated lactate. By 72–96 hours, she developed progressive hypoxemic respiratory failure with bilateral infiltrates fulfilling Berlin criteria for moderate acute respiratory distress syndrome (ARDS) (PaO₂/FiO₂ nadir ≈115 on FiO₂ 1.0), preceded by fever and culture-proven lower respiratory and urinary tract infections, resulting in sepsis and disseminated intravascular coagulation (DIC). She required escalation from non-invasive to invasive mechanical ventilation, with lung-protective strategies, targeted antibiotics, component therapy for DIC and early magnesium and calcium supplementation. Despite markedly elevated N-terminal pro-B-type natriuretic peptide with preserved biventricular function on echocardiography and transient acute kidney injury, she made a full clinical recovery and was discharged with normal oxygenation and functional status. This case underscores that delayed moderate ARDS with superimposed sepsis and DIC can complicate initially stable aluminium phosphide poisoning and highlights that meticulous, protocol-based supportive care can still result in survival in this rarely reported scenario.