Finding into death of Brett Maybus

60y · Male·Haemorrhage complicating a left robotic upper mediastinal lymph node clearance in a man with metastatic squamous cell carcinoma, secondary to rupture of a blood vessel compromised by previous radiation therapy

Brett Maybus, aged 60, died from massive haemorrhage following robotic mediastinal lymph node dissection for recurrent metastatic squamous cell carcinoma. The coroner found the fatal bleed was likely caused by rupture of a blood vessel compromised by previous high-dose radiotherapy to that region. The critical clinical lesson concerns informed consent: while the patient was a well-informed, intelligent man who consented to surgery, the surgeons did not adequately disclose the specific heightened risk of vascular damage from prior radiation in that anatomical zone. The coroner noted this was a material risk that should have been explicitly conveyed to enable fully informed consent. Although the coroner concluded the patient would likely have consented anyway given his limited curative options, the failure to document and specifically discuss this radiation-specific risk in medical records represents a preventable gap in the consent process.