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The deceased, a 36-yr-old man, died during an operation to remove a bronchial carcinoid tumor from his left lung. The case of death was a massive bleed that occurred intraoperatively when the pulmonary artery was injured. The surgeon had failed to adequately prepare for this known risk of the procedure by gaining proximal control of the artery. As a result, the deceased bled to death on the surgical table.
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