Inquest into the Death of Anne RZEPCZYNSKI

59y · Female·complications of intra-abdominal sepsis, including multi-organ failure and bowel perforation, following median hepatectomy for cholangiocarcinoma

59-year-old woman died from intra-abdominal sepsis, multi-organ failure and bowel perforation following median hepatectomy for cholangiocarcinoma. Key clinical issues included: surgical delays of 20 days between stent insertion and operation (affecting bile duct inflammation and infection risk); post-operative complications of arterial bleeding requiring re-operation; bile leak from anastomoses; conservative management of intra-abdominal collections with delayed intervention; lack of specialist liver surgeon during post-operative period; and inadequate nutrition for approximately 10 days. While the coroner found post-operative care generally reasonable, independent experts identified failures: not performing CT scan and starting antibiotics on 3 January when intra-abdominal collections and elevated infection markers were identified; and delay in draining infected collections until 20 January. The combination of pre-operative delay, post-operative bleeding, bile leak, sepsis, and nutritional deficiency created a cascading spiral of complications.