A Royal Adelaide Hospital patient died after he was wrongly diagnosed with cancer and had part of his lung unnecessarily removed, a coronial inquest has heard.
Broken Hill man Dennis "Jacko" Charles Jackson died from pneumonia in January 2019.
In the months prior, the 67-year-old had travelled to the Royal Adelaide Hospital (RAH) for a biopsy.
The inquest heard his biopsy sample became cross-contaminated at the SA Pathology laboratory with the cancerous tissue of another patient, which led to Mr Jackson being incorrectly diagnosed with lung cancer.
He then underwent "unnecessary" surgery to remove part of his lung in August 2018.
Counsel Assisting the Coroner Emma Roper said Mr Jackson's treating doctors will tell the inquest they would not have referred Mr Jackson for that surgery if "he had returned a negative result for any cancerous cells advancing from the biopsy".
"It is expected that your honour will hear evidence that when the excised lung was analysed there was in fact no evidence of malignancy … that the lesion was in fact a granuloma," she said.
A granuloma is a small area of benign inflammation.
The inquest heard the hospital later informed Mr Jackson of their errors and apologised to him and his family.
The inquest heard Mr Jackson sustained nerve damage to his left vocal cords from the procedure which an expert cardiothoracic surgeon believed was "indicative of a surgical error".
"It is anticipated that Professor [Julian[ Smith will give evidence to the effect that the left upper lobectomy surgery was associated with the injury … to the nerve," Ms Roper said.
"In his report, he has expressed the view that there was no need for Dr Edwards to dissect very close to the left … nerve.
"For that reason, he's expressed the view that the injury was probably indicative of a surgical error."
Mr Jackson was discharged from hospital a few weeks after his surgery but was struggling to eat, drink and swallow and he could not taste or smell anything.
He returned to the RAH a month later via ambulance when his respiratory failure worsened.
He spent months in intensive care but he continued to deteriorate and he developed further complications before he died in January 2019.
Ms Roper said the inquest would examine what role the pathology contamination, wrong diagnosis and unnecessary surgery had on Mr Jackson's death.
'There needs to be a different procedure'
The head of Anatomical Pathology at Victoria's The Alfred Hospital, Professor Catriona McLean, told the inquest the procedures at the RAH's pathology lab were "not as detailed as it should be".
She said in no other laboratory would it be considered "satisfactory" to just wipe down rather than "burn" the forceps used while obtaining and analysing biopsy samples.
"It's obviously what they do in South Australia but it is not the procedure that we do in our lab," Professor McLean told the inquest.
"I think that the technology's wrong.
"There needs to be a different procedure."
She said the risk of contamination in a pathology lab was "entirely possible" but the likelihood of that occurring was "entirely dependent on the laboratory's quality assurances".
Mr Jackson was remembered during the inquest as a "devoted husband" who cared for his wife, Ramonda, who died the same year as her husband.
The born-and-bred Broken Hill man worked in the mines, at the power station and as a carpet layer.
Calls for better practice at SA Pathology
Outside court, Mr Jackson's niece, Tanya Williams, said her uncle was "well-known and well-liked" and hoped the inquest would lead to change so no other family lost a loved one in the same way.
"He was friendly with everybody, got along with anyone and everybody," she said.
"There were a lot of people who were very shocked about what happened.
"I'm hoping that what will come out of this is SA Pathology's procedures will become a lot more thorough than what they've been.
"I hope they stand up and take a lot more responsibility for handling people's lives."
Ms Williams said it was incredibly tough watching him die in hospital.
"For my uncle, it was like going to hospital and getting hit by a train and then leaving hospital and getting hit by another train and then going back into hospital and knowing he was never going to come out," she said.
"Being from Broken Hill, it wasn't accessible for his friends to come and see him. He had a shocking life in the hospital."
The inquest before Deputy State Coroner Ian White continues.
