Non-inquest findings into the death of Mr C

62y · Male·Intraoperative haemorrhage due to metastatic clear cell renal cell carcinoma (surgical treatment)

A 62-year-old man died from intraoperative haemorrhage during surgery for a renal tumour initially diagnosed as benign anastomosing haemangioma on biopsy but found at autopsy to be metastatic clear cell renal cell carcinoma. The decision to operate was reasonable based on available preoperative pathology and imaging, made by experienced surgeons after multidisciplinary review. However, the tumour proved inoperable with extensive hepatic invasion and IVC involvement. Multiple intraoperative factors contributed to poor outcomes: late recognition of blood loss, delay in activating massive transfusion protocol, loss of central line preventing vasopressor administration, inadequate team communication, and suboptimal fluid resuscitation. The coroner found none of these issues were outcome-changing given the tumour's invasiveness. Key lessons include earlier recognition of massive bleeding, improved team communication, and careful pre-operative assessment of complex cases.