SA Coroner’s recommendations into death of Kathleen Ethel Salter, after surgery at Clare Hospital

The death of a grandmother whose bile duct was mistakenly cut during gall bladder surgery at a rural SA hospital could have been prevented, a coroner has ruled.

A South Australian grandmother’s death could have been prevented after a surgeon mistakenly cut into the woman’s bile duct during gall bladder surgery, a coroner has found.

In her findings published online on Thursday, Deputy State Coroner Naomi Kereru made two recommendations after an inquest into Kathleen Ethel Salter’s death.

Mrs Salter, 76, went in for elective surgery at Clare Hospital on May 20, 2020 where her surgeon, Dr Darren Lituri, found her gall bladder to be inflamed and embedded into her liver.

“Upon the removal of the gall bladder, a significant bleed was discovered which saw Mrs Salter very quickly become haemodynamically unstable,” Ms Kereru said.

“Due to the level of inflammation, Dr Lituri had in fact become misorientated and clipped the wrong structures, being the common bile duct and the hepatic artery.

“He was not aware of his error at this time.”

Mrs Salter was stabilised with two units of O-negative blood, which were past their use-by date.

She was transferred to the Royal Adelaide Hospital where her condition improved until June 3, 2020, when she developed septic shock.

Mrs Salter was taken to the Royal Adelaide Hospital where she later died. Picture: NCA NewsWire/Brenton Edwards

Due to Mrs Salter’s ongoing deterioration and poor prognosis, a decision was made to withdraw treatment and she died on June 4, surrounded by her family.

Her cause of death was determined to be multi-organ failure and sepsis due to complications of the surgery.

Ms Kereru said while it was “undesirable” the blood was a few hours out of date, it was determined the benefit far outweighed the risk in the circumstances.

“This ultimately prevented Mrs Salter from suffering fatal hypovolaemia in the Clare Hospital operating theatre,” she said.

“Furthermore, a process was put into place after Mrs Salter’s surgery to ensure that this would not occur in the future.”

In his evidence during the inquest, Dr Lituri explained that he should have made the decision to re-book Mrs Salter’s surgery when he observed the inflamed gall bladder at the beginning.

He described becoming “misorientated” during the surgery, which led to him likely clipping the bile duct by mistake, and feeling “frazzled” while trying to locate and contain the bleeding.

“Everything is happening very quickly and it’s not something that you particularly are expecting in an elective procedure,” he said.

Dr Lituri said that, upon reflection, he should have referred Mrs Salter to a metropolitan hospital for the surgery when he noted the gall bladder to be inflamed and embedded in the liver.

Ms Kereu said she was of the view that Mrs Salter’s death was preventable.

She said the first opportunity was at the point where Dr Lituri identified Mrs Salter’s gall bladder to be unexpectedly inflamed.

“This was the point at which Dr Lituri should have (and duly acknowledged) re-booked Mrs Salter’s surgery at a tertiary hospital,” she said.

“Had he done so, the injuries to the common bile duct, the hepatic artery and the portal vein would not have occurred.”

Ms Kereru said it was evident the events deeply affected Dr Lituri, to the point that he self-elected to stop performing cholecystectomy surgery for a period of time and sought further training.

She said the second opportunity related to the unavailability of a CT cholangiogram at Clare Hospital, which would have assisted in re-orientating Dr Lituri from the incorrect area.

As a result, Ms Kereru recommended having CT cholangiogram facilities at all rural sites in South Australia where elective cholecystectomy is performed.

She also recommended training be provided in the surgical program on the importance of minimising harm by not continuing with procedures with unexpected circumstances of high risk.

Originally published as SA Coroner’s recommendations into death of Kathleen Ethel Salter, after surgery at Clare Hospital