Finding into death of Md Fakrul Alam Sozon

33y · Male·Haemoperitoneum secondary to lacerated spleen as a result of peritoneal ascitic fluid tap procedure, on a background of liver failure with veno-occlusive liver disease

A 33-year-old man with severe alcoholic liver disease (Child-Pugh C) and poor prognosis died from haemoperitoneum following splenic laceration during a diagnostic ascitic tap procedure. Two junior doctors (HMOs/Basic Physician Trainees) performed the procedure unsupervised without formal ultrasound training, mistaking the spleen for ascitic fluid. Critical failures included: absence of senior supervision despite protocol suggesting registrar oversight, lack of formal ultrasound competency training and credentialling, failure to use percussion technique as per protocol, and misinterpretation of ultrasound imaging. While the coroner found no adverse findings against the junior doctors who acted under instruction and appropriately abandoned the procedure when complications arose, significant clinical governance failures were identified. The coroner could not find the death preventable given the patient's terminal prognosis, but emphasised missed opportunities for appropriate care and recommended formal ultrasound training and credentialling systems.