A fifty-seven-year-old man presented to a hospital for a hernia repair. Following the operation, laboratory studies, failure to urinate, dropping blood pressure and pain indicated the patient was probably bleeding internally.
The laboratory findings and the dropping blood pressure were not acted upon and approximately 36 hours following the surgery, the patient died as a result of the internal bleeding. At the time of autopsy, over a liter of blood was found in the patient’s abdomen.
The case was particularly tragic in that the dropping blood pressure and absence of urination was not acted upon by a number of nurses, residents, or attending physicians.
Following the patient’s death, a top hospital administrator informed the patient’s wife that her husband had probably died of blood clots to the lung, even though he knew laboratory studies confirmed the patient had bled to death.