Coroner's Finding: Pears, William Ernest

66y · Male·hepatic failure, intrahepatic sepsis and intrahepatic haematoma secondary to complications following laparoscopic cholecystectomy

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.