SAhospital

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. Report an inaccuracy.

Specialties

general surgeryanaesthesiaintensive care

Error types

diagnosticproceduraldelay

Drugs involved

apixabanatenololcephalothinceftriaxonemetronidazolevasopressorscrystalloid fluids

Clinical conditions

chronic cholecystitisxanthogranulomatous cholecystitisgallstonesatrial fibrillationsleep apnoeaobstructive jaundicehepatic ischaemiaportal vein injuryhemorrhagic shockmulti-organ failuresepsishepatic encephalopathyacute renal failurebowel ischaemia

Procedures

laparoscopic cholecystectomyconversion to open cholecystectomy (laparotomy)emergency laparotomy at RAHright hemi-hepatectomyleft hepato-jejunostomyperitoneal lavageintubationintraoperative cholangiography (not performed)blood transfusion

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

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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.

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