A coronial inquest into the death of a man who died after bowel surgery in a NSW hospital has heard his family did not get to say goodbye to him properly.
William Edmunds, 79, from Oaklands, died in the intensive care unit at Albury Base Hospital on December 2, 2019 from complications of peritonitis.
One of the contributing factors was found to be a failed bowel operation performed on him on November 7, 2019.
That operation, a Hartmann's procedure, was performed by Dr Liu-Ming Schmidt and involved removing a large piece of Mr Edmunds' bowel.
She performed it on the wrong end of his colon — the distal end.
The inquest has already heard that the surgical error was only identified eight days later when a second operation for Mr Edmunds took place.
Deputy State Coroner Erin Kennedy delivered the inquest's formal findings on Thursday.
She found other contributing causes to Mr Edmunds' physical decline and death included the prolonged delays in diagnosis of a mechanical bowel obstruction, together with underlying natural causes.
'They just needed to say goodbye'
During Thursday's inquest proceedings Kate Williams, the legal representative for Mr Edmunds' family, read a prepared statement to the court from Mr Edmunds' son and daughter, Wade and Susan.
"They just needed to say goodbye," Ms Williams said.
The court also heard Mr Edmunds loved to drive trucks, have a beer, and watch horse races.
The statement said he loved the nurses who cared for him and that the family believed they loved him too.
But the family also raised concerns about how Dr Schmidt had communicated with them about Mr Edmunds' care following the first operation — a matter which was brought up throughout the inquest.
They said lessons needed to be learned from how key developments were passed on to them.
"The communication was not there and it was handled poorly," Ms Williams read.
"They [the family] hope it [the inquest] changes the way daily communications are [handled] throughout Albury Wodonga Health and no families endure what they have endured."
Analogy an 'oversimplification'
The inquest also heard from two medical experts this week about the decisions made by Dr Schmidt.
They were doctor Alan Meagher, a specialist in colorectal surgeries, and Paul Myers, a vascular surgeon and associate professor.
Both were asked whether they agreed with a comment made earlier in the inquest that performing a Hartmann's procedure was "like riding a bike".
"Once you’re completely trained and have a fellowship in surgery, you should be able to do it," Dr Myers said.
Dr Meagher said he considered that analogy an "oversimplification" and that for those not specialising in colorectal surgeries, procedures such as Hartmann's could be complicated.
He said he did not think Dr Schmidt recognised that Mr Edmunds' anatomy was distorted during the initial failed operation.
"I think that's the central point here," Dr Meagher said.
"I would recognise it almost certainly. I can recognise someone who doesn't do it often wouldn't recognise it."
Counsel assisting the coroner Matthew Robinson asked him whether it should have been recognised.
"In an ideal world," Dr Meagher replied.
During closing submissions on Thursday, Mr Robinson said that throughout the inquest there had been some evidence that Mr Edmunds' anatomy had not been particularly distorted and some that it had.
He said Dr Schmidt should have been able to identify that.
"If this anatomy was so distorted, why could Dr Schmidt not appreciate that?" he said.
The inquest had previously heard that Dr Schmidt had only performed one Hartmann's procedure in the five years prior to November 7, 2019.
It heard about two of the procedures were performed at Albury Base Hospital every week.
The inquest's final findings and recommendations are expected to delivered in several weeks' time.
