Coroner's Finding: Pears, William Ernest
Deceased
William Ernest Pears
Demographics
66y, male
Date of death
2015-09-08
Finding date
2020-04-03
Cause of death
hepatic failure, intrahepatic sepsis and intrahepatic haematoma secondary to complications following laparoscopic cholecystectomy
AI-generated summary
William Ernest Pears died from hepatic failure, intrahepatic sepsis and haematoma following a laparoscopic cholecystectomy in 2012. During surgery for gallstone disease, the right hepatic duct was damaged and repaired, but critically, damage to the left hepatic duct went undetected. This undiagnosed injury led to ongoing complications including infections and bile duct problems requiring multiple subsequent surgeries over three years. The coroner found that operators encountering laparoscopic difficulties should consider converting to open surgery or abandoning the procedure. The undetected left hepatic duct injury appears to have been the root cause of Mr Pears' subsequent deterioration. Early recognition of this injury might have prevented the cascade of complications that ultimately proved fatal.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- undetected damage to left hepatic duct during initial surgery on 20 July 2012
- pathological anatomy with scarring and fibrosis making dissection difficult
- damage to right hepatic duct requiring repair
- subsequent surgeries that may have exacerbated rather than ameliorated the underlying injury
- difficulty in detecting the left hepatic duct injury on imaging
- radiological report confusion
Coroner's recommendations
- Operators should consider alternatives such as open procedure or abandoning the laparoscopic cholecystectomy when difficulties are encountered during the procedure
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