Coronial
WAhospital

Inquest into the Death of Cyril CHURCHILL

Deceased

Cyril CHURCHILL

Demographics

68y, male

Coroner

Coroner Jenkin

Date of death

2017-11-13

Finding date

2021-03-26

Cause of death

surgical complications following laparoscopic cholecystectomy for cholecystitis, specifically intra-abdominal bleeding from inadvertent cutting of aberrant branch of cystic artery leading to sepsis and multiple organ dysfunction syndrome

AI-generated summary

Cyril Churchill, a 68-year-old man with multiple comorbidities, died from surgical complications after laparoscopic cholecystectomy for acute cholecystitis. Postoperatively, he developed profound hypotension. The treating team disagreed on whether the cause was internal bleeding or sepsis. A diagnosis of bleeding should have been reached earlier based on clinical signs, blood test results, and the rapidity of deterioration. Approximately 3.5 hours elapsed before return to theatre, where 3 litres of blood was evacuated from an aberrant branch of the cystic artery. Subsequent sepsis and multiple organ failure followed. Key lessons: blood loss is the default diagnosis in acute post-operative shock; FAST scans have significant limitations and are unreliable in post-operative settings; drain settings must be verified; effective communication and leadership during MET calls are critical; and when clinicians disagree, early escalation to senior medical officer should occur.

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

Specialties

general surgeryanaesthesiaemergency medicineintensive care

Error types

diagnosticcommunicationsystemdelay

Clinical conditions

acute cholecystitislaparoscopic cholecystectomyhaemorrhagic shocksepsismultiple organ dysfunction syndromeacute kidney injuryischaemic bowelcongestive heart failuretype 2 diabetes mellituschronic kidney disease

Procedures

laparoscopic cholecystectomyabdominal drain insertionFAST scanarterial line insertionreturn to theatre for haemostasis

Contributing factors

  • failure to recognize internal bleeding as primary diagnosis in timely manner
  • diagnostic uncertainty between sepsis and haemorrhage
  • drain placed on gravity setting rather than low suction, rendering it ineffective
  • limitations of FAST scans in post-operative setting with insufficient detection of free fluid
  • lack of definitive imaging (CT scan) at earlier stage
  • poor communication between anaesthetist and surgeon
  • absence of clear leadership during MET call
  • failure to escalate to Senior Medical Officer
  • lack of policy guidance on FAST scan use
  • inadequate documentation and missing clinical records
  • locum surgeon unfamiliar with local procedures and with limited rapport with team

Coroner's recommendations

  1. WACHS should develop a policy for point of care ultrasound (PoCUS) including FAST scanners, setting out minimum education, training and credentialing requirements and appropriate clinical circumstances for use
  2. WACHS should amend its Health Records Management Policy to provide guidance as to what constitutes a medico-legal report
  3. WACHS should amend its Health Records Management Policy to provide that clinician entries are not to be removed, left unfiled or deleted; any removal must be clearly documented in the health record with reasons; and documents must be retained
  4. WACHS should improve communications between clinicians, including a process to resolve disagreements in a timely manner
  5. WACHS should amend its Clinical Escalation Including Code Blue – Medical Emergency Response Policy to clearly identify the MET team leader at the start of the call and when that role changes
Full text
Official source Archived copy

Related cases from WA

WAhospitalAugust 2023

Inquest into the Death of Justin DOBSON

46y · Male·sepsis following haemorrhoidectomy

46-year-old Justin Mark Dobson died from sepsis following a routine haemorrhoidectomy on 17 July 2019. He was discharged to the ward overnight but deteriorated significantly from 11:00 am on 18 July, showing hypotension,…

general surgerycolorectal surgerydiagnosticcommunicationmetronidazole
WAhospital2022-06-23

Inquest into the Death of Lee MILCHERDY

75y · Female·Complications including acute pancreatitis and refractory intra-abdominal sepsis…

Lee Milcherdy, 75, died from complications including acute pancreatitis and refractory intra-abdominal sepsis following an unnecessary ERCP procedure. An MRCP scan on 12 October 2018 showed no gallstone, making the plann…

gastroenterologygeneral surgerycommunicationdiagnostic
WAhospital2021-09-14

Inquest into the Death of Jeremy Michael SCOTT

63y · Male·metastatic rectal carcinoma

Jeremy Scott, a 63-year-old prisoner, died from metastatic rectal carcinoma on 3 July 2017. From 2015 onwards, he reported rectal and anal symptoms including pain, bleeding, and palpable masses, which were repeatedly att…

general surgerycolorectal surgerydiagnosticcommunication

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.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.