A 76-year-old grandmother was given out-of-date blood, had gauze left inside her, and had a number of “unexpected injuries” following gall bladder surgery at a hospital in regional South Australia, an inquest into her death has heard.

The South Australian Coroner’s Court heard that Kathleen Ethel Salter went in for surgery at Clare Hospital on May 20, 2020.

But five hours later, after suffering heavy blood loss, she was medically retrieved to the Royal Adelaide Hospital.

When the inquest began on Friday, counsel assisting the coroner, Darren Evans, said in his opening statement that surgeon Darren Lituri had “encountered inadvertent bleeding” during key-hole surgery that he had controlled using gauze swabs.

“The bleeding was difficult to stop,” Mr Evans said.

Kathleen Ethel Salter was flown to Royal Adelaide Hospital hours after her initial surgery.(ABC News: Che Chorley)

Mr Evans said Dr Lituri finished the surgery before a decision was made to fly Mrs Salter to Adelaide.

“While waiting for MedSTAR to arrive, the medicine team identified that the operation account sheet was incorrect and that four gauze packs were missing, presumably left inside Mrs Salter’s abdomen,” Mr Evans said.

“A full investigation was conducted by SA Health into this error but there is no suggestion that it had any clinical impact.”

Mr Evans said two units of O negative blood had also been given to Mrs Salter, despite it being 12 hours out of date.

The court heard that decision had been made because of the seriousness of her condition.

“A full investigation was conducted by SA Health into this aspect of Mrs Salter’s care and again there are no suggestions that this had any clinical impact,” Mr Evans said.

The court heard surgeon Chuan Tan treated Ms Salter when she arrived at the Royal Adelaide Hospital later on May 20.

Dr Chuan Tan found a “number of unexpected injuries” when he treated Mrs Salter later that day.(ABC News: James Wakelin)

Mr Evans said Dr Tan found the four missing gauze packs during surgery.

“There was bile leaking, there were also a number of unexpected injuries,” Mr Evans said.

“Over the days that followed Mrs Salter’s condition fluctuated.

“Her organs began failing; first her kidney and then her heart.

“There was a brief improvement before signs of septic shock appeared, which worsened until Mrs Salter’s family agreed with advice to withdraw further treatment.”

Mrs Salter died on June 4.

The cause of death was found to be because of “multi-organ failure and sepsis due to complications” of gall bladder surgery.

When asked about Mrs Salter’s internal damage, Dr Tan said it was difficult to give an opinion.

“I’m still at a loss to explain how that could have happened,” Dr Tan said.

Mr Evans then asked Dr Tan if he thought Dr Lituri had become “anatomically lost” during the surgery.

“You would probably say that he had navigational issues,” Dr Tan said.

“Most things are possible when you’re facing big bleeding and you can’t really see what you’re doing.

“I wasn’t there, I can’t tell you what he’s done, but I can envisage that scenario happening.”

Dr Darren Lituri says he was “horrified” by what had happened.(ABC News)

Dr Tan questioned whether it was an appropriate surgery to be done at a country hospital and added that a “more experienced doctor” may have handled the surgery differently.

On Monday, the court heard that Dr Lituri was unable to conduct a cholangiogram – a type of imaging of the bile ducts used during surgery – because Clare Hospital did not have the appropriate equipment.

The court heard that during the surgery, Dr Lituri had mistakenly cut into Mrs Salter’s bile duct instead of the cystic duct.

Mrs Salter suffered heavy bleeding during the surgery, but Dr Lituri did not know the cause at the time.

Dr Lituri, who has performed the same procedure many times before, acknowledged during questioning that if a cholangiogram showed a surgeon was in the wrong spot, the principle was to “immediately stop the operation”.

Despite this, the surgeon said the absence of this equipment did not justify initially referring Mrs Salter to another hospital.

In a statement provided to the court, Dr Lituri said there were “no red flags” to indicate the surgery should not be done at Clare Hospital.

Dr Lituri said Mrs Salter was not keen to be near Adelaide given the COVID-19 situation unfolding there at the time.

The court heard a report from an expert witness, Robert Padbury, stating that there were “always bail-out options available … which would maximise the likelihood of avoiding damage”.

In response, Dr Lituri said that “on reflection … it would have been more appropriate to think, ‘No I need to abandon this procedure before I even start.'”

Dr Lituri, who has since moved to Queensland, said he now only removed gall bladders when a cholangiogram could be done.

The inquest continues.