A pneumonia patient who needed intensive care was instead discharged from a Mount Barker hospital with a cannula still in her arm, the Coroners Court has heard.
Lynne Patricia Fisher, who had five children and six grandchildren, died in September 2018 from sepsis due to pneumonia.
An inquest into the 60-year-old's death has heard Ms Fisher's husband took her to the Mount Barker District Soldiers' Memorial Hospital on the evening of September 26 because she was struggling to breathe and was confused.
The inquest heard she had a very low oxygen saturation rate of 84 per cent and was put on oxygen while at the hospital.
However, the court heard she was discharged in the early hours of the morning despite her oxygen saturation levels declining once she was taken off the gas.
Hours after her discharge, Ms Fisher collapsed at her Balhannah home in the Adelaide Hills and was unable to be revived, despite efforts of paramedics and medical staff at the Royal Adelaide Hospital.
Counsel assisting the inquest, Sally Giles, told the court she would call expert evidence from emergency physician Anne-Marie Kelly that Ms Fisher should have been in intensive care.
"Professor Kelly's evidence will be that Ms Fisher was suffering moderate to severe pneumonia, which carries significant risk of mortality and for which inpatient hospital treatment is recommended," she told the court.
"Professor Kelly will tell Your Honour that it was not appropriate for Ms Fisher to be discharged on that evening, in fact, she should probably have been transferred to a hospital capable of providing ICU level care that was required."
The court heard Ms Fisher would likely have survived if she was given appropriate care.
"Professor Kelly is of the opinion that Ms Fisher's death was preventable and had she been appropriately risk-stratified and treated, it is more probable than not that she would have survived," Ms Giles told the court.
Ms Giles said there were multiple red flags in Ms Fisher's medical condition that should have prompted an escalation in her care.
"Ms Fisher presented to the Mount Barker Soldiers' Memorial Hospital with not one but five red flags indicating that inpatient treatment was required," she said.
Discharged with cannula still in arm
The court heard the paramedics who later attempted to resuscitate Ms Fisher discovered a cannula used in her treatment at the Mount Barker hospital was still in her arm.
"This played no part in Ms Fisher's demise and death, but in my submission may have been a consequence of the lack of clarity around the discharge plan and the lack of attention paid to Ms Fisher at the time of discharge," Ms Giles said.
The inquest will examine assessments made by Dr Fenella Livesey, who initially assessed Ms Fisher and recommended she be discharged, as well as any assessments made by locum Dr Mei Leng, who took over as the only doctor on duty at the hospital overnight.
The court heard the clinical handover between the two doctors was not documented.
"The evidence that Your Honour will hear during this inquest will illuminate what I suggest are a number of concerning aspects of Ms Fisher's treatment at the Mount Barker Soldiers' Memorial Hospital," Ms Giles said.
The inquest will also examine whether hospital processes were followed "and if not, why not?"
"The pneumonia treatment protocol in place at the Mount Barker hospital at the time was seemingly not followed by either Dr Livesey or Dr Leng," Ms Giles told the court.
The court heard Ms Fisher had been unwell for two weeks before her death and had seen a GP the day before she went to the Mount Barker hospital.
That GP diagnosed her with a chest infection and prescribed an antibiotic.
The inquest, heard by Coroner Naomi Kereru, is due to hear evidence from multiple witnesses including Dr Livesey, Dr Leng and expert witness Professor Kelly.
