Coronial
VIChospital

Finding into death of Gary William Bruce

Deceased

Gary William Bruce

Demographics

71y, male

Date of death

2023-06-03

Finding date

2025-10-15

Cause of death

Complications following a right hepatic artery injury following an open cholecystectomy in the setting of previous splenectomy and small bowel resection

AI-generated summary

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 intraoperative injury was appropriately managed. However, critical deficiencies occurred in post-operative care: the patient met MET call criteria on 10 occasions overnight but only one MET call was activated at 1 am (2 hours after initial hypotension at 11 pm). This delay prevented timely senior clinician involvement and surgical re-exploration. An arterial line requested for 24 hours post-op was inexplicably removed. Earlier MET activation would likely have enabled earlier return to theatre and potentially different outcome. The coroner emphasised this was a systems failure in escalation protocols rather than an operative error.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

general surgeryanaesthesiaintensive carehaematologyemergency medicine

Error types

communicationsystemdelay

Clinical conditions

acute cholecystitischolelithiasismyelofibrosispolycythaemia rubra verahepatic artery injuryhypovolaemic shockmetabolic acidosisacute kidney injuryatrial fibrillationpulmonary oedemacritical illness weakness

Procedures

open cholecystectomyexploratory laparotomyarterial line insertionblood transfusionintubationcontinuous renal replacement therapy

Contributing factors

  • failure to activate Medical Emergency Team calls when clinically indicated
  • delayed recognition and escalation of post-operative deterioration
  • inadequate supervision and communication between junior medical staff and senior clinicians overnight
  • removal of arterial line without clear clinical justification or documentation
  • lack of senior critical care physician presence in High Dependency Unit overnight
  • poor adherence to hospital escalation policies

Coroner's recommendations

  1. ERH should undertake improved education, training and awareness of the Hospital's deteriorating patient response with its medical and nursing staff and gather evidence to demonstrate improvement amongst its staff
  2. ERH should consider implementing a mechanism by which anaesthetic or other critical care trained specialists such as ICU or ED staff are available to provide advice to a junior doctor who attends MET calls overnight
Full text
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Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

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