Death of great-grandmother could have been prevented following gall bladder surgery at Clare Hospital, inquest finds
A great-grandmother who died after gall bladder surgery at a regional South Australian hospital could still be alive if a surgeon had abandoned the procedure earlier or had access to a CT scan, a coroner has found.
Deputy State Coroner Naomi Kereru found there were "two primary opportunities" that could have prevented the June 2020 death of Kathleen Ethel Salter, 76.
Mrs Salter died at the Royal Adelaide Hospital after experienced surgeon Dr Darren Lituri "clipped the wrong structures" during gall bladder surgery at the Clare Hospital in the state's Mid North.
During the inquest, the court heard Mrs Salter suffered a significant bleed and was given blood that was more than 12 hours out of date, and had four gauze packs left inside her — but that neither of those incidents had "any clinical impact".
Her cause of death was found to be due to "multi-organ failure and sepsis due to complications".
Ms Kereru found the first opportunity to prevent Mrs Salter's death occurred when Dr Lituri identified her gall bladder to be "unexpectedly inflamed" and embedded into the liver when he began operating, after pre-surgical tests did not reveal anything unexpected.
"It was at this point Dr Lituri should have abandoned the procedure and rescheduled for another time and at a metropolitan hospital," she said.
Instead, she said Dr Lituri kept operating but "due to the level of inflammation, Dr Lituri had in fact become misoriented and clipped the wrong structures, being the common bile duct and the hepatic artery".
"He was not aware of this error at the time."
Mrs Salter was transferred to the RAH and had further surgery but later died.
Ms Kereru said the second opportunity to prevent Mrs Salter's death related to the availability of a cholangiogram CT machine — an imaging tool that she said was "important to assist with determining the anatomy before the gall bladder is removed".
"This would have illuminated the anatomical area in which Dr Lituri was and should not have been, providing him an opportunity to correct himself," Ms Kereru said.
She said had Dr Lituri had access to a CT cholangiogram, "he would have utilised this tool to assist him to identify the critical view of safety".
"Had this tool been available to Dr Lituri, Mrs Salter's death could have been prevented."
During the inquest, Dr Lituri had told the court that he now only removed gall bladders when a cholangiogram could be done.
Ms Kereru made a recommendation that the Health Minister give consideration to the provision of CT cholangiogram facilities at all rural sites in the state where elective gall bladder surgery occurs.
She also recommended to the Royal Australasian College of Surgeons that training be provided to surgical trainees on the "importance of minimising harm" by not continuing with procedures when unexpected "high-risk" circumstances arise.
Ms Kereru also noted that three separate external reviews were conducted after Mrs Salter's care and that Clare Hospital had since changed its processes to prevent out-of-date blood from being given in the future.
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