Deceased
Bryan Lindsay Cleeman
Demographics
86y, male
Coroner
Deputy State Coroner Paresa Spanos
Date of death
2015-10-02
Finding date
2019-01-24
Cause of death
Complications post laparoscopic cholecystectomy
AI-generated summary
86-year-old man with acute gangrenous perforated cholecystitis underwent laparoscopic cholecystectomy on 2 October 2015, forty-two hours after admission. Severe bleeding from hepatic arterial branches required conversion to open surgery, CPR, and massive transfusion. Myocardial infarction occurred intraoperatively in a patient with underlying coronary artery disease and was unresuscitable. While the delay between admission and surgery (outside 72-hour guideline window) raised family concerns, the coroner found the delay was reasonable given the competing surgical demands and Mr Cleeman's stable condition. HMIT concluded that earlier surgery may have had a different outcome but this could not be determined with certainty. The core clinical lesson is that perforated cholecystitis in an elderly patient with cardiac comorbidities carries high perioperative risk; however, the surgical response to major intraoperative bleeding was appropriate.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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A 71-year-old man with myelofibrosis and prior abdominal surgery died from complications of a right hepatic artery injury during open cholecystectomy for acute cholecystitis. The operative decision was reasonable and the…
82y · Female·Peritonitis due to leakage of bowel contents from bowel anastomosis following el…
Winifred Carpenter, 82, died 11 days after a right hemicolectomy for colon cancer from peritonitis due to anastomotic leak. Critical failures occurred on discharge day (10 March 2023): clinicians did not recognize her de…
58y · Male·complications of large bowel pseudo-obstruction
Paul Desmond Smith, aged 58, died from complications of large bowel pseudo-obstruction following discharge from hospital after inadequate assessment. He had presented to the ED with lower abdominal pain and severe faecal…
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