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The decedent, a 36-year-old man, died during an operation to remove a bronchial carcinoid tumor from his left lung. The cause of death was a massive bleed that occurred intra-operatively 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.