Inquest into the death of Ali Achmadun Djawas

70y · Male·multi-organ failure due to septic shock consequent on faecal peritonitis due to anastomotic leak following elective laparoscopic right hemicolectomy

Ali Djawas, a 70-year-old Indonesian-born man with comorbidities (hypertension, diabetes, COPD), underwent elective right hemicolectomy on 13 March 2017 for a suspicious ileo-caecal lesion. Biopsies were benign, CT imaging negative, yet surgery proceeded. Critical failures included: inadequate informed consent (risk of death not disclosed despite being material; language barrier ignored; consent form incompletely completed); unnecessary surgery (expert opinion suggests conservative surveillance was appropriate); and catastrophic discharge communication (family not informed of anastomotic leak risk, complications, warning signs, or urgency of return). Post-operative recovery proceeded well until day 6 when he was discharged. On day 10, he developed an anastomotic leak with subsequent septic shock. Late re-admission and emergency surgery could not prevent multi-organ failure. Death was preventable through: (1) appropriate pre-operative decision-making with multidisciplinary team input; (2) proper informed consent with risk disclosure; and (3) comprehensive discharge communication enabling early recognition and return.