Finding into death of Robert Vivian Hawkins

55y · Male·Multi-system failure complicating intra-operative haemorrhage due to inadvertent superior mesenteric artery ligation during laparoscopic nephrectomy for renal cell carcinoma

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 L. 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 L.'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 L.'s qualifications met competency standards despite having performed fewer than 40 procedures.