Coroner calls for new staghorn kidney stone guidance
Surgeon should have been suspicious it was an infected stone, finds magistrate
A coroner has called for new guidance around the management of large staghorn kidney stones after a woman died of sepsis following a high-risk surgical procedure on an infected stone.
Pauline Kessell, 53, died in 2015 of multiple organ failure resulting from septic shock two days after undergoing endoscopic pyeloscopy with laser lithotripsy for a 5cm staghorn calculus at Westmead Private Hospital in Sydney.
Magistrate Paula Russell found that the sepsis was caused by endotoxins and Proteus mirabilis bacteria released from the infected stone by increased intrarenal pressure during the prolonged procedure.
The stone was the largest “by a considerable margin” the urological surgeon had treated using pyeloscopy.
