Finding into death of H YR

77y · Female·Haemoperitoneum following cholecystectomy

A 77-year-old woman died from haemoperitoneum (intra-abdominal bleeding) three days after elective laparoscopic cholecystectomy. Bleeding from the left inferior epigastric artery was a recognised surgical complication but was not identified until 12:14 pm on day 3, despite clinical signs from 9:30 am. Key failures included: delayed CT imaging (90 minutes after MET call), inadequate fluid and blood resuscitation (only 1 unit PRBC over 2 hours despite confirmed haemorrhage), failure to check coagulation status until 7:45 pm despite therapeutic anticoagulation, lack of urinary catheter insertion until 8:00 pm, delayed antibiotic administration, and poor inter-team communication and documentation. The coroner found the patient likely would have survived with earlier diagnosis and aggressive resuscitation, though angioembolisation rather than open laparotomy was performed.