Coroner's Inquest Reveals Preventable Death of Great-Grandmother After Surgery

A coroner's inquest into the death of Kathleen Ethel Salter, a 76-year-old great-grandmother, has concluded that her tragic demise following gall bladder surgery at Clare Hospital in South Australia could have been prevented. The inquest, led by Deputy State Coroner Naomi Kereru, highlighted critical lapses in medical judgment and the lack of essential imaging technology that contributed to Salter's complications and eventual death in June 2020.

Kathleen Salter underwent gall bladder surgery at Clare Hospital performed by experienced surgeon Dr. Darren Lituri. According to the findings presented during the inquest, the procedure encountered unforeseen complications when Salter's gall bladder was found to be unexpectedly inflamed and embedded in the liver, a condition not indicated by pre-surgical tests. Coroner Kereru emphasized that Dr. Lituri should have aborted the operation at this juncture. Instead, he proceeded, ultimately misidentifying critical anatomical structures and inadvertently clipping both the common bile duct and the hepatic artery.

"It was at this point Dr. Lituri should have abandoned the procedure and rescheduled for another time and at a metropolitan hospital," Ms. Kereru stated. The coroner further noted that had Dr. Lituri had access to a cholangiogram CT scan—a diagnostic imaging tool crucial for assessing the anatomy before gall bladder removal—he might have avoided the mistakes that led to Salter's death.

Salter was transferred to the Royal Adelaide Hospital for further surgery but succumbed to multi-organ failure and sepsis as a result of surgical complications. The inquest revealed that she had received blood that was over 12 hours past its expiration date during her initial surgery, although this was noted not to have a clinical impact on her outcome.

In response to the findings, Coroner Kereru made several recommendations, including the establishment of CT cholangiogram facilities at all rural hospitals performing elective gall bladder surgeries. She also called for enhanced training for surgical trainees on the importance of halting procedures in high-risk situations.

Dr. Darren Lituri, who has since changed his practice to only conduct gall bladder surgeries when cholangiograms are available, expressed his regret over the incident during the inquest. He acknowledged the critical importance of proper imaging in preventing similar tragedies in the future.

The case has raised questions about the adequacy of surgical facilities in regional areas and the protocols in place to ensure patient safety. Health Minister Chris Picton has been urged to consider the provision of necessary medical technologies in rural sites, ensuring that patients receive the highest standard of care regardless of their geographical location.

The inquest has also triggered a review of practices at Clare Hospital, where procedural changes have been implemented to ensure that outdated blood is no longer administered to patients. Salter’s family has expressed hope that the recommendations will lead to tangible changes in the healthcare system, preventing future tragedies.

As healthcare systems worldwide continue to grapple with the challenges of providing quality care in rural settings, the implications of this inquest extend beyond South Australia, highlighting the urgent need for systemic reforms that prioritize patient safety and technological advancement in medical practices.