Coroner's Finding: Salter, Kathleen Ethel

76y · Female·multi-organ failure and sepsis due to complications of cholecystectomy

A 76-year-old woman died from multi-organ failure and sepsis following a laparoscopic cholecystectomy at a rural hospital. During surgery, the surgeon became misoriented in the inflamed surgical field and divided the common bile duct, right hepatic artery, and right portal vein instead of the cystic structures. The underlying pathology—xanthogranulomatous cholecystitis—could not be detected preoperatively. The coroner found the death preventable: the surgeon should have abandoned the procedure upon observing unexpected gallbladder inflammation, and intraoperative CT cholangiography (unavailable at the rural site) would have allowed correction of the anatomical misidentification. The case highlights risks of performing complex surgery in resource-limited settings without bailout options and diagnostic tools.