A Calvary Hospital patient died after "errant clinical judgments" and systemic failures did not give him "the chance of survival", the ACT Coroner's Court has found.
The court also apologised to the family for its delay in progressing the inquest and for its "poor levels of communication".
Maarouf El-Cheikh died at the hospital in March 2016 after first becoming unwell at his home.
Initial tests by ambulance officers showed it was likely septicaemia, an infection of the bloodstream.
When Mr El-Cheikh - who had multiple health conditions, including type 2 diabetes, heart diseases, and a brain injury - arrived at the hospital's emergency department, a provisional diagnosis showed sepsis.
Mr El-Cheikh's condition deteriorated during the night and he was never transferred to the intensive care unit before going into cardiac arrest.
Hospital staff performed CPR; however, he was pronounced dead about 7.10am the following day.
An autopsy concluded the cause of death was "streptococcus pneumonia septicaemia due to splenectomy".
Two experts reviewed Mr El-Cheikh's treatment and they made a number of criticisms relating to various issues, including the emergency department's treatment, overall care, and contribution to the patient's death.
Dr Astrid Arellano, an infectious diseases physician from Perth, was critical of the failure to admit Mr El-Cheikh to the ICU.
"He had severe lactic acidosis and this alone is a strong predictor of death. It is also a sign of severe illness," Dr Arellano said.
"This plus the rest of his clinical picture should have prompted rapid referral and transfer to an ICU where all his medical issues could have been carefully managed."
Dr Arellano said the overall care the patient received "did not give him a real chance of survival" and the cardiac arrest "was a predictable outcome".
The doctor acknowledged that Mr El-Cheikh was seriously ill and "may not have survived even with ICU care".
However, she said with adequate doses of antibiotics "administered in a timely manner" and with adequate supportive care, "there is a chance he may have survived".
Associate professor David Bihari, an intensivist from Sydney, said he believed Mr El-Cheikh should have been admitted to the ICU "as soon as possible" after his admission.
He said "undoubtedly" the treatment Mr El-Cheikh received was below "the standard of care that is accepted in metropolitan Australia".
Other issues the two experts also criticised were the monitoring of urine output, administration of antibiotics, and monitoring of blood.
A hospital representative said they extended "our condolences to Mr El-Cheikh's family".
"Calvary thanks coroner [Ken] Archer for reporting the findings and recommendations of the inquest into the death of Mr Maarouf El-Cheikh," the representative said.
"As advised to the coroner, extensive changes have been made to clinical governance, practice guidelines and escalation procedures in the Calvary Hospital Emergency Department.
"Many of these were informed by the review of Mr El-Cheikh's treatment and the implementation of these changes was noted by the Coroner."
Mr Archer, who in February 2022 was appointed the ACT's dedicated coroner, in his decision earlier this week said the experts' criticisms about Mr El-Cheikh's treatment in the emergency department were not challenged and were accepted.
He said he found there were matters of public safety related to the patient's care, which he said was suboptimal.
"I do not find that those deficiencies in his care were the difference between life and death or that they contributed to his death," Mr Archer said.
"However, I do find that the suboptimal standard of care he received did not give him the chance of survival."
Mr Archer said apart from "the errant clinical judgments I have identified", there were "systemic failings that led to suboptimal care".
These failures were inadequate or poorly applied sepsis treatment protocols; unduly restricted access to infectious diseases physicians; a hesitancy in escalating a patient care issue and the lack of a culture that encouraged staff to raise care concerns, if necessary, with a more senior clinician above clinicians rostered on shift; and, inadequate number of doctors rostered to overnight shifts.
Since Mr El-Cheikh's death, the hospital has made changes, including an updated sepsis protocol reflecting changes to international sepsis guidelines.
Further, additional medical staff, including an on-call emergency consultant, has been added to the overnight shift.
Mr Archer said he made "no criticisms of individual clinicians" because "the evidence otherwise suggests that the deficiencies in care were not attributable to a single clinician".
He said the "disposition of the inquest in this case has taken far too long" and that a statutory obligation under the Coroners Act has not been discharged.
"On behalf of the Coroner's Court, an apology is made to the family for that delay and the poor levels of communication with them as to the progress of the inquest," Mr Archer said.
