Coroner's Finding: Suckling, James William

72y · Male·hypovolemic shock due to haemoperitoneum following surgical repair of an abdominal wall hernia

A 72-year-old man died from hypovolemic shock due to intra-abdominal haemorrhage following Spigelian hernia repair. Post-operatively he presented with hypotension, bradycardia and sweating. ECG changes were misinterpreted as ST-elevation myocardial infarction, leading to inappropriate diagnosis of cardiogenic shock and treatment with anticoagulation and antiplatelet agents. Critical failures included: non-provision of clinical notes at transfer, failure to seek surgical review despite recent operation, and failure to reconsider diagnosis despite mounting evidence (normal troponin, insufficient ECG changes for cardiogenic shock, falling haemoglobin). Appropriate post-operative haemorrhage recognition and surgical intervention likely would have been life-saving. Key lesson: post-operative haemorrhage can mimic acute coronary syndrome; clinicians must maintain high suspicion and consider bleeding in all post-operative deterioration.