As an elderly man moaned and struggled to get out of his hospital bed in the final hours of his life, a nurse rebuked him: "You're not even close to dying, so don't even try it."
The 75-year-old was in Wagga Wagga hospital after a knee replacement in February 2017, when he was bullied and belittled by nurse Jennifer Hogg, according to a NSW Civil and Administrative Tribunal ruling.
Another patient was so disturbed by the exchange, he recorded it on his phone, capturing Ms Hogg saying: "It is an elective procedure. We didn't make you do it. You didn't need it. It's not life or death."
The man died soon after.
The tribunal in 2019 found Ms Hogg guilty of professional misconduct, and she was barred from practice for more than three years.
The recording was given to police, prompting a coronial inquiry into the man's death.
Handing down her findings this week, Deputy State Coroner Joan Baptie said there were serious deficiencies and shortcomings in the hospital's treatment of the former mining worker.
The man, who had multiple conditions affecting his heart and kidneys, was admitted to Temora hospital on February 4 and discharged two days later despite abnormal blood readings, the inquest heard.
Ms Baptie said he was "somewhat surprisingly" admitted to Wagga Wagga hospital for the knee replacement on February 10, without further review of his condition.
The operation was successful and the man was initially able to walk on crutches, but his blood pressure began to fluctuate as he showed symptoms of severe kidney problems.
Ms Baptie found these symptoms were poorly recorded and communicated by staff at both hospitals, and there was a lack of senior medical staff to supervise at Wagga Wagga.
A panel of experts told the inquest the man should have been carefully reviewed before, during and after the surgery given his health conditions, and a mix of medications at the hospital likely worsened his kidney disease.
As his condition deteriorated dramatically on the evening of February 15, he was abused and ridiculed by the nurse, stripping him of his dignity, Ms Baptie said.
"Patients with complex comorbidities need to be identified, managed and not subjected to abuse," Ms Baptie said.
"Many of these patients with complex comorbidities are over 65 years of age.
"It is an area of significant concern in terms of public health and safety, particularly with an ageing population in rural and regional NSW and Australia."
Ms Baptie found the man had ultimately died of natural causes in the context of his medical history, but recommended the Murrumbidgee health district consider establishing a model of care for surgery patients with comorbidities.
The death of the man, described as a decent "knock around" bloke, may never have been investigated without the other patient's recording of the abuse, she said.
