Coroner's Finding: MCSHANE Robert Ian
Deceased
Robert Ian McShane
Demographics
66y, male
Date of death
2013-01-08
Finding date
2016-09-29
Cause of death
Multi-system failure and ischaemic gut after left nephrectomy complicated by massive haemorrhage and vascular grafting
AI-generated summary
A 66-year-old man died from multi-system failure and ischaemic bowel following laparoscopic left nephrectomy complicated by massive haemorrhage and vascular injury. During surgery for renal carcinoma, the surgeon attempted to control bleeding from an unidentified vessel using a laparoscopic stapler without adequate visualisation of the stapler tips. This resulted in transection of the abdominal aorta and right renal artery. Although vascular surgeons successfully repaired the aorta, the patient developed irreversible intestinal ischaemia. The coroner found that the surgeon's decision to use the stapler without clear visualisation of critical vessels was an error of judgment. Key lessons include: never deploy staplers without complete visualisation of contents in the jaws, consider earlier conversion to open surgery when laparoscopic bleeding cannot be controlled, and ensure adequate surgical assistance and senior support for complex laparoscopic cases.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Failure to adequately visualise stapler jaws before deployment
- Accidental transection of abdominal aorta by laparoscopic stapler
- Accidental transection of right renal artery
- Delayed conversion to open surgery
- Poor visibility in laparoscopic field during bleeding
- Unfamiliar operative angles due to altered port placement
- Inadequate identification of bleeding vessel
- Resulting intestinal ischaemia from aortic injury
- Massive blood loss requiring large transfusion
Coroner's recommendations
- All hospitals at which laparoscopic procedures are carried out should be required to make and keep a visual recording of the vision that the operator was able to see through the camera via the monitor during surgery
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —