Coroner's Finding: Salter, Kathleen Ethel
Deceased
Kathleen Ethel Salter
Demographics
76y, female
Date of death
2020-06-04
Finding date
2025-06-12
Cause of death
multi-organ failure and sepsis due to complications of cholecystectomy
AI-generated summary
A 76-year-old woman died from multi-organ failure and sepsis following a laparoscopic cholecystectomy at a rural hospital. During surgery, the surgeon became misoriented in the inflamed surgical field and divided the common bile duct, right hepatic artery, and right portal vein instead of the cystic structures. The underlying pathology—xanthogranulomatous cholecystitis—could not be detected preoperatively. The coroner found the death preventable: the surgeon should have abandoned the procedure upon observing unexpected gallbladder inflammation, and intraoperative CT cholangiography (unavailable at the rural site) would have allowed correction of the anatomical misidentification. The case highlights risks of performing complex surgery in resource-limited settings without bailout options and diagnostic tools.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- surgeon misorientation due to florid inflammation obscuring anatomical landmarks
- xanthogranulomatous cholecystitis—a rare, undetectable preoperatively condition causing extensive surrounding tissue inflammation
- lack of intraoperative CT cholangiography at rural hospital
- failure to abandon procedure upon observation of unexpectedly inflamed gallbladder
- intrahepatic gallbladder positioning increasing surgical difficulty
- iatrogenic transection of common bile duct
- iatrogenic division of right hepatic artery
- iatrogenic injury to right portal vein
- absence of senior surgical support at rural facility
- expedited surgery date reducing time for comprehensive planning
Coroner's recommendations
- To the Minister for Health and Wellbeing: Consider provision of CT cholangiogram facilities at all rural sites in South Australia where elective cholecystectomy is performed
- To the Royal Australasian College of Surgeons: Provide training to surgical trainees on the importance of minimising harm by not continuing with procedures attended by unexpected high-risk circumstances, and develop a supportive culture around bailout decisions
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 —