Medical experts tell jury Hugo Chetcuti ‘would have died immediately’ if he had not been operated upon

Emergency doctors give jury account of battle to save Hugo Chetcuti’s life

If he had not been operated upon, Hugo Chetcuti “would have died immediately,” medical experts have told a jury trying Bojan Cmelik for Chetcuti’s murder.

Chetcuti, an entertainment entrepreneur who owned several establishments in Malta’s nightlife district, was stabbed on 6 July 2018 in Triq Santa Rita in Paceville. Cmelik was apprehended by the police shortly afterwards.

Medico-legal specialist Dr. Mario Scerri was one of several medical experts who testified in the jury trial of Bojan Cmelik, the 38-year-old Serbian former bouncer accused of Chetcuti’s murder.

Dr. Scerri told Mr. Justice Aaron Bugeja and a jury of 12 men and women that he had coordinated the forensic investigation into the stabbing. He examined both Chetcuti and Cmelik.

Dr. Scerri presented the jury with a slideshow of his findings, explaining what he found.

Cmelik had fresh bruising on his face, abrasions on the back of the left ear, bruises on the left side of the chest and on his legs. A drug test returned negative for illegal substances.

“His injuries were not compatible to a beating but to when a person resists arrest,” Scerri said. “They were all of a slight nature.”

Chetcuti’s wounds were caused by a cutting instrument with one cutting edge. A knife with such an edge was found on Cmelik’s person, he said. “This is a stab wound inflicted by a sharp instrument with one cutting edge. The instrument found is such an instrument.”

The knife went into the victim at one orientation before being twisted and pulled out in another, said Scerri, as he listed the various wounds inflicted on Chetcuti.

If he had not been operated on, Chetcuti “would have died immediately.”

One stab wound can affect various parts of the bowels as they are coiled, explained the expert in reply to a question from the prosecution.

Asked what the cause of death was, he said the victim had developed septicaemia and his blood became toxic. The septicaemia was caused by the leaking of the contents of the bowel, he said, which caused peritonitis. The stab wound produced perforations in the bowel. “The blood loss was not the issue, the issue was the perforations of the bowel. It so happened that during the second operation, a third perforation was found.”

Cross-examined by defence lawyer Simon Micallef Stafrace, Dr. Scerri was asked whether the death ensued because something was missed. “It was a wise decision to re-operate. It’s not the first time that things like this happen,” replied Scerri, adding that the third perforation was just millimetres away from the second.

“Was the death of Mr Chetcuti an inevitable consequence of the stabbing?” posited the lawyer.

“Mr Chetcuti was a healthy man, he was happy, he was drinking. He received two stab wounds,” the doctor began, going on to say that the operation to stop the bleeding was successful.

“By the time you went to see him at 7pm he was already in a bad state?” asked Micallef Stafrace. “A full 12 hours passed before the decision to operate again. Was it [the death] inevitable?”

“Was the perforation there when it was operated on? Was it invisible?...If you miss something either it was not there or invisible to the naked eye. He reported two puncture wounds. There might have been a third one that he missed or was so small that it was missed, ” explained Scerri.

“So I’m correct in saying that the cause of death was not the fact of the stabbing,” said the lawyer. “Death is not inevitable in stabbings.”

“In 2021, or 2018 in this case, it’s anathema for a patient to die of a stab wound to the abdomen… but at the same time, complications do arise.”

The prosecution pointed out that there were three pairs of eyes looking on during the first operation.

“The most obvious possible cause is a missed perforation during the first operation,” Dr. Scerri went on. “The second possible reason was that a lot of time passed between the first and second operation. But there might have been other causes, the surgeon might have missed the perforation as it was a tiny nick, which was exacerbated by peristalsis, the normal movement of the bowel. It might not have been possible to see it.”

Peristalsis causes the bowel to elongate and contract, explained the expert, stressing that he was not blaming the surgeon. “The bowel is not static.”

As the jury sitting carried on into the evening, pathologists Dr. Marie Therese Camilleri and Dr. Safraz Ali presented their findings to the jury. “The cause of death was septicaemia following bowel perforation caused by stab wounds,” Camilleri said. “This perforation was due to stabbing,” Ali concurred.

Surgeons testify about their struggle to save Hugo Chetcuti

Emergency physicians told the jury that they had to move fast to save stabbing victim Hugo Chetcuti’s life on the night of his wounding.

Dr. Jonathan Joslin told the jurors that Chetcuti was still talking coherently but he was seriously injured and in a state of shock when he saw him in the emergency department at 10:54pm.

Taking the witness stand on Thursday, the consultant emergency physician testified about the incident after explaining the protocols adopted by Mater Dei Hospital concerning serious incidents.

At the time, Dr Joslin was on call when he was informed about a serious stabbing in Paceville at 10.43pm by the hospital’s central control room. Whilst driving towards the scene of the stabbing in Paceville, Dr Joslin was informed that the victim had been taken to Mater Dei Hospital in a private vehicle and he re-routed towards the Emergency Department, where a trauma team was already treating the patient.

“When I came in, he was already being assessed and first line treatment was being administered. The patient was a man, Hugo Chetcuti. He was anxious, pale, sweaty, talking coherently but was in a state of hemorrhagic shock.” He had very low blood pressure and was feeling faint, added the doctor.

A fast ultrasound was carried out and found blood in the abdomen.

Chetcuti was admitted at 10:54pm, 11 minutes after the stabbing. “He had two incised wounds. One in the upper quadrant in a C-shape by a single edge blade. The knife was either twisted or the victim twisted himself. It was roughly 1cm long. We were giving him blood but his blood pressure was still low so surgery had to be performed.”

Chetcuti went straight to the operating theatre, having lost around two litres of blood. He was transferred to operating theatre around 30min after the stabbing.

Showing photos of the injuries to the jurors, Dr Joslin explained that a C-shaped wounds were in the upper quadrant of the abdomen.

The patient was in Class 3 shock due to significant blood loss. “There are 4 classes,” explained the specialist. “At class 3. He is quite significantly shocked.”

Asked who took the decision to operate, the doctor said it would have been the surgeons. “There would be a team discussion and from the clinical findings…it was best to move him straight to the operating theatre.”

Dr Joslin was not present for the surgery but was informed that there was a significant amount of blood in the abdomen.

Emergency physician Dr. Josef Mifsud was another member of the medical staff on duty at the time who were summoned to testify in Cmelik’s trial for Chetcuti’s murder. Dr. Mifsud, an experienced specialist in emergency medicine, had treated Chetcuti first upon his admission to hospital.

“I was writing notes at my desk and there was a commotion. A woman started shouting that there was a stabbing. I stood up and took the ultrasound machine with me to the resuscitation room. My role was to lead with the resuscitation. I have a team with me and called the surgeons as well as carrying out the initial assessment.”

A fast ultrasound scan showed blood in the abdominal cavity. “His pulse was fast, blood pressure was low and the ultrasound showed free fluid in the abdomen. In this case it was blood…The patient was agitated, anxious and these factors all point to class 3 shock.”

Dr. Mifsud said that the patient was in a critical condition. A transfusion was administered and the cause of the bleeding was sought, said the doctor. The ultrasound showed internal bleeding.

“If he had been more stable we would have done a CT scan but he was in too frail a condition and would have died on the scanner,” Dr. Mifsud said.

“So he would have died if you waited any longer?” “Most probably, yes.”

This was confirmed by the third witness, surgeon Ayman Mostafa, a senior registrar at Mater Dei Hospital, who also operated on Chetcuti. Mostafa also said the patient would have died in the CT scanner as he wasn’t in a stable enough condition …”he was safer in surgery than in the CT scanner.”

The surgeon said that he had made stitches to close the bleeding points. .

“At the end of the operation we check the points and make sure there is no more bleeding. After 10 or 15 minutes the bleeding was controlled by stitches. Patient became more stable.”

More medical professionals testified today, including Chetcuti’s personal physician, consultant surgeon Alex Attard.

Attard was Chetcuti’s personal physician for many years. Prosecution asked that he be exempted from professional secrecy to allow him to testify on facts relating to Chetcuti prior to the incident in question. Parte civile lawyer Mario Spiteri said his clients were exempting Attard from his duty to secrecy.

“In a sense I was his general physician. I visited him in intensive care and he woke up while I was there. I was not on call when he was admitted but I requested that he be under my care. This was after the first surgery.”

Attard said he had been called from the hospital the next morning and went to see his patient, noticing that the abdomen was distended. “I suspected a perforation. This required immediate surgery.” A CT scan confirmed his suspicions and Attard went with Chetcuti into theatre.

“There was a lot of free air and infected material… pus surrounding his intestine. There was a small hole near one of the wounds.” The hole was very small so air could escape but fluid less easily. There was also a small amount of bowel content, Attard said.

The surgeon excised the damaged part of the intestine and joined the rest up.

The hole he had found was very small and was also missed by the pathologist when the excised portion was sent to him, said the surgeon.

“The actual site of this ‘later hole’ if you like, was in the first 12 inches of the small intestine – a difficult area to work in as it is stuck to the abdomen.” The mesenteric surface, a curtain like structure where blood vessels are, hid the later hole.

“One of the possible reasons for what happened post-operation was that that part of the intestine had its blood supply interrupted…if you have a wound you need a good blood supply to heal.

After the operation Chetcuti was initially responding well to treatment, but later it was evident that there was an infection, Attard said. “Blood samples showed a nasty virulent bacteria in the blood. This has a high mortality rate. I changed his antibiotics …and subsequent cultures showed it was the right antibiotic to use. But despite this the infection overwhelmed Mr. Chetcuti,” explained the clinician.

“As the infection progresses there is almost total body shutdown,” said the surgeon. “Most of the treatment was directed at maintaining the vital parameters, keeping his kidneys and lungs working and so on, but despite a lot of effort his condition was getting worse instead of better.”

Cross-examined by defence counsel Simon Micallef Stafrace, the surgeon told the jury that the tiny perforation was “a few millimeters” from the sutures.

“The perforation in question is what made his condition deteriorate on the 7th to the 8th July,” concluded the surgeon.

“When we first opened him up…it wasn’t obvious. Sometimes its obvious others it’s not. In this situation it wasn’t obvious.”