A coroner is investigating the death of an Oaklands man after botched surgery at Albury hospital, with an inquest told a doctor made a massive error.
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William John Edmunds, 79, died on December 2, 2019, after undergoing a procedure on November 7 of that year.
Dr Liu-Ming Schmidt had performed the bowel operation at Albury hospital, with Monday's coronial inquest told an expert was "highly critical of that surgical error" made during the procedure.
"I find it difficult to imagine how an error of this magnitude could have occurred," an expert noted in their report.
The late man's two surviving children, Wade and Sue, attended Albury court on Monday to hear details of their father's passing.
"This inquest is of interest to many, but none more so than both of you," coroner Erin Kennedy said to the pair.
"I just want to extend my deepest condolences to you."
The coroner said the inquest would explore what happened to their father, what issues could be identified, and what could be improved.
Counsel assisting, Matthew Robinson, said the inquest would examine whether Dr Schmidt, who also appeared at the inquest, was sufficiently qualified for the procedure.
Mr Robinson said the surgical error would be examined, along with the appropriateness of her completing the surgery without assistance.
A large number of doctors and experts will give evidence, including Dr Schmidt, this week.
Mr Robinson said it wasn't in dispute that a significant error had occurred during the operation.
Much of Monday's summary involved complex medical terminology.
The error involved the distal end of Mr Edmunds' colon being closed off.
He didn't resume bowel movements in the days after the surgery, and it had been noted he had been in more pain that would be expected after such a procedure.
The inquest heard the late man had serious health problems before the operation, including high blood pressure, heart failure, emphysema, chronic obstructive pulmonary disease, an enlarged prostate and arthritis.
His neighbour had called Triple-0 on October 23, 2019, and he was taken to Goulburn Valley Health for treatment due to Albury Wodonga Health experiencing a code black.
He was transferred to Corowa a week later, and was later discharged, with medical notes stating he had no abdomen related issues at the time.
The 79-year-old was taken to Albury hospital in the early hours of November 7 after he complained of bowel pain, with medical staff treating the matter as life threatening.
An examination showed his bowel was perforated.
Dr Schmidt was called in and arrived at 3.15am, and later stated she needed to perform immediate surgery, or "the patient would die within hours".
The surgery started at 4.15am and concluded at 5.35am.
The serious issues with the surgery - which involved parts of the bowel being misidentified - weren't discovered until days later, and there were concerns Dr Schmidt failed to openly disclose the failings to Mr Edmunds and his family.
A nurse made a note stating "open disclosure did not occur at this point in my opinion".
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A rescue procedure was later conducted in a bid to fix the problems, which was delayed due to his condition.
Improvements had been noted before Mr Edmunds suffered an infection.
He was placed in palliative care and died.
Albury Wodonga Health ordered an external review of Dr Schmidt.
The review found the surgery wasn't performed competently.
Her ability to perform major abdominal surgery was removed in June 2020.
She was then removed from the health provider's on-call roster and suspended from the health provider completely.
She said she remains suspended from Albury Wodonga Health.
The inquest heard she had self reported to the Australian Health Practitioners Regulation Agency following the incident.
The inquest is scheduled to run until Friday.
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