Finding into death of Bryan Lindsay Cleeman

86y · Male·Complications post laparoscopic cholecystectomy

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.