Finding into death of Bryan Lindsay Cleeman
Deceased
Bryan Lindsay Cleeman
Demographics
86y, male
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.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- Acute gangrenous perforated cholecystitis
- Bleeding from hepatic artery during surgery
- Underlying coronary artery disease
- Myocardial infarction intraoperatively
- High surgical risk due to significant inflammation
- Delay in surgery (42 hours between admission and operation, with second 24-hour delay due to surgical team unavailability)
Coroner's recommendations
- Ballarat Health Services should review emergency surgery capacity with a view to ensuring patient access to clinically-indicated emergency surgery is optimized even in the setting of multiple competing demands on surgical resources
- BHS should address not only theatre availability but also ensure adequate surgical team capacity to perform emergency surgery in a timely manner
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