Finding into death of Bernas Hasibuan

Contributing factors

• failure to escalate severe hypotension (systolic <90) to MET call on three occasions
• failure to activate MET call criteria despite documented hypotension on 11 November and 15 November
• misdiagnosis of bleeding as diverticular disease rather than post-operative complication
• failure to perform gastroscopy when upper GI bleeding suspected
• inadequate investigation of unexplained haemoglobin drop from 130 to 78
• failure to use gastrointestinal bleeding protocol
• use of haemodilution as explanation for blood loss rather than ordering transfusion
• incomplete communication between surgical teams and senior clinician
• poor handover between night and day teams
• inadequate clinical documentation by senior surgeon
• failure of supervising surgeon to receive crucial information about patient deterioration
• surgical separation of adherent duodenum from friable gallbladder with unrecognised consequential injury
• inappropriate discharge of clinical responsibility to incoming team without MET escalation

Coroner's recommendations

1. Implementation of mandatory MET call activation when systolic blood pressure falls below 90, removing discretionary override by treating team
2. Adoption of gastrointestinal bleeding protocol when upper GI bleeding is suspected post-operatively
3. Performance of gastroscopy to locate bleeding source when dark per rectal bleeding occurs with hypotension and declining haemoglobin
4. Improved escalation of care guidelines with mandatory activation rather than clinical discretion
5. Enhanced supervision of newly appointed junior medical officers, particularly regarding MET call criteria and escalation decisions
6. Improved clinical documentation and note-taking by senior clinicians during patient reviews
7. Structured handover processes between shifts and teams to ensure critical clinical information is communicated
8. Ensuring supervising surgeons are informed of significant deterioration in their patients' condition
9. Use of comprehensive observation charting and regular haemoglobin monitoring in post-operative patients with unexplained deterioration
10. Implementation of family communication pathway to allow family members to report concerns about patient deterioration