Coronial
VIChospital

Finding into death of Kenneth James Anderson

Deceased

Kenneth James Anderson

Demographics

85y, male

Coroner

Deputy State Coroner Paresa Spanos

Date of death

2023-12-22

Finding date

2025-10-28

Cause of death

Liver ischaemia and portal vein thrombosis complicating emergency cholecystectomy secondary to acute cholecystitis

AI-generated summary

Kenneth James Anderson, an 85-year-old man with intellectual disability and multiple comorbidities including diabetes, pancreatitis, and gallstones, died following emergency cholecystectomy for acute cholecystitis with Mirizzi's syndrome. Intraoperative complications included major bile duct injury, right hepatic artery transection, and portal vein occlusion—all iatrogenic injuries from difficult dissection in inflamed tissue. Despite appropriate management of complications, the patient developed liver ischaemia and portal vein thrombosis, leading to multi-organ failure. The coroner found no want of care: surgery was necessary (patient would have died of sepsis), consent was appropriate, preoperative imaging was standard, and the extent of Mirizzi's syndrome could only be identified intraoperatively. Surgeons responded appropriately to unexpected complications. The death was an accepted surgical risk in a high-risk patient.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

general surgeryintensive careemergency medicine

Drugs involved

antibiotics

Clinical conditions

acute cholecystitisgallstonesMirizzi's syndromenecrotising pancreatitisseptic shocksepsisliver ischaemiaportal vein thrombosisportal vein occlusiontype II diabetes mellitusgastro-oesophageal reflux disease

Procedures

cholecystectomylaparoscopic cholecystectomyconversion to open cholecystectomyportal vein thrombectomyhepatic resectioncholangiogramcomputed tomographyultrasound

Contributing factors

  • acute cholecystitis with gallstones
  • Mirizzi's syndrome (undiagnosed preoperatively)
  • previous necrotising pancreatitis
  • septic shock
  • aberrant and unrecognisable vascular anatomy
  • difficult dissection due to acute and chronic inflammation
  • major iatrogenic bile duct injury
  • iatrogenic right hepatic artery transection
  • iatrogenic right portal vein occlusion
  • multi-organ failure
Full text

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