She was 76 and died after routine surgery—‘Had this tool been available' she might still be alive
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Medical procedures in regional hospitals are meant to follow strict safety protocols, especially when dealing with vulnerable patients.
But when something goes wrong during what should be a routine operation, families are often left searching for answers.
A recent inquest has revealed concerning oversights that may have contributed to a tragic and preventable death.
A surgeon’s decision to proceed with a high-risk operation at a regional South Australian hospital has come under scrutiny following the death of a 76-year-old great-grandmother.
Kathleen Ethel Salter underwent gall bladder surgery at Clare Hospital in June 2020—an operation that resulted in a fatal outcome after serious complications emerged during the procedure.
A recent coronial inquest revealed that there were two key moments where her death could have been prevented, had different decisions been made.
Dr Darren Lituri, the surgeon at the centre of the case, began the operation with no indication from pre-surgical tests that anything was unusual. But once inside, he discovered that Mrs Salter’s gall bladder was ‘unexpectedly inflamed’ and embedded into her liver.
Despite this unexpected and dangerous complication, he chose to continue with the surgery rather than halt and reschedule it at a better-equipped metropolitan hospital.
‘It was at this point Dr Lituri should have abandoned the procedure and rescheduled for another time and at a metropolitan hospital,’ Deputy State Coroner Naomi Kereru found.
Instead, the procedure went ahead—leading to what Ms Kereru described as a critical error. Dr Lituri, she said, had become misoriented and ‘clipped the wrong structures, being the common bile duct and the hepatic artery’. He had no idea he’d made the mistake until much later.
Mrs Salter was later transferred to the Royal Adelaide Hospital, where she underwent further surgery but ultimately died from ‘multi-organ failure and sepsis due to complications’.
The inquest also uncovered that four gauze packs had been left inside her body and that she was given blood that was more than 12 hours out of date. However, Ms Kereru noted that these issues had no clinical impact on her cause of death.
Another significant finding involved the absence of a CT cholangiogram machine—an imaging tool that could have clarified the internal anatomy during the operation. Ms Kereru said the machine’s availability could have changed the course of events entirely.
‘This would have illuminated the anatomical area in which Dr Lituri was and should not have been, providing him an opportunity to correct himself,’ she said. ‘Had this tool been available to Dr Lituri, Mrs Salter’s death could have been prevented.’
During the inquest, Dr Lituri told the court that he now only performs gall bladder removals when a cholangiogram can be done.
Ms Kereru recommended that the Health Minister consider ensuring CT cholangiogram facilities are available at all rural hospitals where elective gall bladder surgeries take place. She also advised the Royal Australasian College of Surgeons to include training for surgical trainees that emphasises the importance of stopping procedures when unexpected, high-risk complications arise.
In her findings, Ms Kereru acknowledged that three external reviews had been conducted into Mrs Salter’s care and that Clare Hospital had since updated its protocols to prevent the use of out-of-date blood in future cases.
This isn’t the first time Australia’s healthcare system has faced serious questions over patient safety—especially in high-pressure hospital settings.
For those wanting to better understand how systemic issues can impact care, this report is well worth a watch.
Source: Youtube/60 Minutes Australia
With more surgeries being performed in regional hospitals, do you think enough is being done to protect vulnerable patients in high-risk situations? Let us know your thoughts in the comments.
In a previous story, we looked into the heartbreaking case of a man who had his jaw mistakenly removed during surgery—raising serious questions about hospital safeguards.
For those who often rely on the healthcare system more frequently, stories like these highlight how crucial accurate diagnoses and clear communication truly are.
If medical mishaps concern you, that one’s worth a read too.
Read more: Doctors removed his jaw by mistake—how could this happen?
But when something goes wrong during what should be a routine operation, families are often left searching for answers.
A recent inquest has revealed concerning oversights that may have contributed to a tragic and preventable death.
A surgeon’s decision to proceed with a high-risk operation at a regional South Australian hospital has come under scrutiny following the death of a 76-year-old great-grandmother.
Kathleen Ethel Salter underwent gall bladder surgery at Clare Hospital in June 2020—an operation that resulted in a fatal outcome after serious complications emerged during the procedure.
A recent coronial inquest revealed that there were two key moments where her death could have been prevented, had different decisions been made.
Dr Darren Lituri, the surgeon at the centre of the case, began the operation with no indication from pre-surgical tests that anything was unusual. But once inside, he discovered that Mrs Salter’s gall bladder was ‘unexpectedly inflamed’ and embedded into her liver.
Despite this unexpected and dangerous complication, he chose to continue with the surgery rather than halt and reschedule it at a better-equipped metropolitan hospital.
‘It was at this point Dr Lituri should have abandoned the procedure and rescheduled for another time and at a metropolitan hospital,’ Deputy State Coroner Naomi Kereru found.
Instead, the procedure went ahead—leading to what Ms Kereru described as a critical error. Dr Lituri, she said, had become misoriented and ‘clipped the wrong structures, being the common bile duct and the hepatic artery’. He had no idea he’d made the mistake until much later.
Mrs Salter was later transferred to the Royal Adelaide Hospital, where she underwent further surgery but ultimately died from ‘multi-organ failure and sepsis due to complications’.
The inquest also uncovered that four gauze packs had been left inside her body and that she was given blood that was more than 12 hours out of date. However, Ms Kereru noted that these issues had no clinical impact on her cause of death.
Another significant finding involved the absence of a CT cholangiogram machine—an imaging tool that could have clarified the internal anatomy during the operation. Ms Kereru said the machine’s availability could have changed the course of events entirely.
‘This would have illuminated the anatomical area in which Dr Lituri was and should not have been, providing him an opportunity to correct himself,’ she said. ‘Had this tool been available to Dr Lituri, Mrs Salter’s death could have been prevented.’
During the inquest, Dr Lituri told the court that he now only performs gall bladder removals when a cholangiogram can be done.
Ms Kereru recommended that the Health Minister consider ensuring CT cholangiogram facilities are available at all rural hospitals where elective gall bladder surgeries take place. She also advised the Royal Australasian College of Surgeons to include training for surgical trainees that emphasises the importance of stopping procedures when unexpected, high-risk complications arise.
In her findings, Ms Kereru acknowledged that three external reviews had been conducted into Mrs Salter’s care and that Clare Hospital had since updated its protocols to prevent the use of out-of-date blood in future cases.
This isn’t the first time Australia’s healthcare system has faced serious questions over patient safety—especially in high-pressure hospital settings.
For those wanting to better understand how systemic issues can impact care, this report is well worth a watch.
Source: Youtube/60 Minutes Australia
With more surgeries being performed in regional hospitals, do you think enough is being done to protect vulnerable patients in high-risk situations? Let us know your thoughts in the comments.
In a previous story, we looked into the heartbreaking case of a man who had his jaw mistakenly removed during surgery—raising serious questions about hospital safeguards.
For those who often rely on the healthcare system more frequently, stories like these highlight how crucial accurate diagnoses and clear communication truly are.
If medical mishaps concern you, that one’s worth a read too.
Read more: Doctors removed his jaw by mistake—how could this happen?
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