Finding into death of Jeanette Brown

66y · Female·Multi-organ failure associated with haemorrhage and sepsis following cholecystectomy

Mrs Jeanette Brown, 66, died from multi-organ failure following post-operative haemorrhage after elective laparoscopic cholecystectomy. Arterial clips applied to the cystic artery during surgery were inadequately secured using a multi-use applicator and subsequently displaced, causing significant bleeding. Critical clinical lessons: profound hypotension at 3.05pm post-operatively was not escalated to senior surgeons and was incorrectly attributed to prior anti-hypertensive medication. Earlier recognition of persistent hypotension as a warning sign of internal bleeding and timely escalation to experienced clinicians would likely have enabled earlier surgical intervention and prevented death. The case highlights importance of escalation protocols for deteriorating patients and junior clinician awareness that compensatory mechanisms can mask severe hypovolaemia.