A significant medical mishap occurred during the gall bladder surgery of Kathleen Ethel Salter at Clare Hospital in South Australia, which led to a series of complications ultimately resulting in her death. The operation, performed by surgeon Darren Lituri, encountered difficulties related to heavy bleeding that required using gauze swabs to control the inadvertent bleeding during the keyhole surgery. Subsequently, it was discovered that four gauze packs were missing and had been left inside Mrs. Salter's abdominal cavity, along with other unexpected injuries identified during the surgery.
Furthermore, Mrs. Salter was given two units of O negative blood that were 12 hours out of date, a decision attributed to the severity of her condition at the time. After experiencing bile leakage and additional injuries, she was transferred to the Royal Adelaide Hospital where her condition deteriorated, leading to organ failure and septic shock. The cause of her death was determined to be multi-organ failure and sepsis due to complications of the gall bladder surgery.
The inquest also highlighted concerns about the surgical procedure itself, with questions raised about the appropriateness of conducting such surgeries at a regional hospital without adequate equipment and expert backup. Surgeon Dr. Lituri faced criticism for mistakenly cutting into Mrs. Salter's bile duct, causing complications during the surgery that were exacerbated by the absence of essential imaging equipment. While Dr. Lituri defended his decision-making during the procedure, acknowledging the need for a cholangiogram to guide surgical accuracy, he admitted that in hindsight, the surgery should have been aborted earlier given the challenges encountered. Dr. Lituri's statements and actions are under scrutiny in the context of ensuring appropriate surgical practices and patient safety moving forward.