A report released Tuesday shows the death of a Calgary man resulted in changes to surgical safety, transfusion, and family support protocols in Alberta hospitals.

Andres Martinez, 24, died in 2010 as the result of a mistake during surgery for appendicitis.

Martinez went into the hospital for a routine appendectomy, but less than 12 hours later he was dead.

His surgeon, who had been working for nearly 17 hours, used the wrong instrument during surgery, which damaged one of Martinez’s blood vessels.

For several hours doctors tried to stop the bleeding, but were unsuccessful.

Provincial court Judge Michael Dinkle wrote “It is clear to me that the tragic death of Andres Martinez was as a result of the improper use of a surgical instrument called disposable trocar,” Dinkle wrote in the report. “If this instrument was, in fact, not present (the doctor) should have waited until it was made available.”

Dinkle’s report identifies several changes that have been made since Martinez died including a surgery safety checklist that ensures all necessary equipment is in the operating room, improvements to a massive transfusion protocol that make blood products immediately available and a family support protocol giving families 24-hour access to a social worker.

Dinkle chose not to make recommendations, but did have some suggestions about educating doctors, informing families about a patient's progress, and timely access to blood products.

Alberta Health Services is refusing to comment.