Finding into death of Bernas Hasibuan

50y · Male·gastrointestinal haemorrhage; haemorrhage from cystic artery post laparoscopic cholecystectomy

A 50-year-old man died from gastrointestinal haemorrhage involving both a cystic artery and duodenal defect following laparoscopic cholecystectomy. Over five days post-surgery, he developed repeated episodes of hypotension, declining haemoglobin, and gastrointestinal bleeding that were not appropriately escalated. Critical failures included: non-activation of MET calls when systolic BP fell below 90 on three separate occasions; misattribution of bleeding to diverticular disease rather than post-operative complications; inadequate investigation of suspected upper gastrointestinal bleeding with gastroscopy not performed when clinically indicated; incomplete handover of clinical information between teams; poor documentation by senior clinicians; and failure of the supervising surgeon to receive crucial information about deterioration. A gastroscopy on days 2-4 post-operation would likely have identified the bleeding source, enabling earlier laparotomy and potentially life-saving intervention.