Cvitic, Nardia Annett

30y · Female·Multi-organ failure due to multiple transfusions required for post-operative bleeding resulting from a bleeding disorder (laceration of external iliac vein)

Ms Cvitic, a 30-year-old woman with cervical cancer, underwent radical hysterectomy on 11 February 2002. She collapsed on 14 February with signs of hypovolaemic shock (haemoglobin 5.3 g/dL). Dr W. performed emergency laparotomy via midline incision, found 1-1.5 litres of 'old blood' but no obvious bleeding source. Rather than continuing systematic exploration of the abdomen via the original transverse incision, he diagnosed pulmonary embolus and administered 10,000 units of heparin. This proved disastrous—post-operative cardiologist Dr C. excluded embolus by transoesophageal echocardiography by midday, yet heparin reversed only after Dr C.'s arrival prompted protamine administration. Dr C. then discovered the actual source: a lacerated external iliac vein, likely injured by the drain trochar on 11 February and tamponaded until dislodged on 14 February. Critical failures included: failure to perform post-operative haemoglobin testing (Dr W.'s direction prevented this); misattribution of symptoms to embolus despite lack of clinical correlation; administering heparin before empiric confirmation; and delayed exploration of the true bleeding site. The coroner found evidence sufficient for criminal negligence charges.