Deceased
Robert Vivian Hawkins
Demographics
55y, male
Coroner
Coroner Jacinta Heffey
Date of death
2010-02-05
Finding date
2014-08-27
Cause of death
Multi-system failure complicating intra-operative haemorrhage due to inadvertent superior mesenteric artery ligation during laparoscopic nephrectomy for renal cell carcinoma
AI-generated summary
Robert Vivian Hawkins, a 55-year-old man, died from multi-system failure following inadvertent ligation of the superior mesenteric artery (SMA) during laparoscopic nephrectomy for renal cell carcinoma. Dr Jonathan Lewin misidentified the SMA for the left renal artery and applied insufficient clipping. Although he recognized the error and converted to open surgery, requesting senior surgical assistance, the bowel became ischaemic. The patient was transferred to Albury Hospital ICU then St Vincent's Hospital where vascular surgeons attempted SMA re-vascularization, but multi-organ failure supervened and the patient died. The inquest examined whether earlier conversion to open surgery, earlier SMA re-vascularization, Dr Lewin's qualifications to perform unsupervised laparoscopic nephrectomy, and the appropriateness of performing the procedure at Wodonga Hospital were issues. The coroner found no criticism warranted in most respects, accepting that vessel misidentification can occur despite competence, that deferring re-vascularization pending transfer was reasonable given the patient's instability and lack of vascular surgery expertise locally, and that Dr Lewin's qualifications met competency standards despite having performed fewer than 40 procedures.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Procedures
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