Inquest into the Death of Cyril CHURCHILL

68y · Male·surgical complications following laparoscopic cholecystectomy for cholecystitis, specifically intra-abdominal bleeding from inadvertent cutting of aberrant branch of cystic artery leading to sepsis and multiple organ dysfunction syndrome

Cyril Churchill, a 68-year-old man with multiple comorbidities, died from surgical complications after laparoscopic cholecystectomy for acute cholecystitis. Postoperatively, he developed profound hypotension. The treating team disagreed on whether the cause was internal bleeding or sepsis. A diagnosis of bleeding should have been reached earlier based on clinical signs, blood test results, and the rapidity of deterioration. Approximately 3.5 hours elapsed before return to theatre, where 3 litres of blood was evacuated from an aberrant branch of the cystic artery. Subsequent sepsis and multiple organ failure followed. Key lessons: blood loss is the default diagnosis in acute post-operative shock; FAST scans have significant limitations and are unreliable in post-operative settings; drain settings must be verified; effective communication and leadership during MET calls are critical; and when clinicians disagree, early escalation to senior medical officer should occur.