An ACT coroner has found the 2016 death of Canberra man Maarouf El-Cheikh at Calvary Hospital occurred after he received "sub-optimal" care that did not give him a "chance of survival"
ACT coroner Ken Archer found Mr El-Cheikh died in the hospital's emergency department amid "errant clinical judgements".
The coroner's findings detailed how Mr El-Cheikh went into cardiac arrest and could not be revived. His cause of death was streptococcus pneumonia septicaemia due to splenectomy.
Experts, who were consulted as part of the coronial, were highly critical of Mr El-Cheik's treatment in the hours before his death.
The inquest found there were a number of signs from the outset to warrant Mr El-Cheikh being transferred to intensive care (ICU) but staff failed to do so.
Poor culture stopped staff escalating patient's needs: coroner
Coroner Archer described systemic failings at the hospital, including inadequate staffing, poor sepsis treatment, unwarranted restrictions on access to infectious diseases physicians, and a culture that stopped staff from escalating patient care issues.
Dr Astrid Arellano, an infectious diseases physician from Perth, assisted the inquiry as an independent expert and said Mr El-Cheikh's condition should have led to "rapid referral and transfer to the ICU".
"Mr El-Cheikh was a seriously ill patient upon arrival at the emergency department. 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.
"His severe medical condition was recognised and judiciously documented throughout the night but not acted upon."
She added that Mr El-Cheikh's cardiac arrest was a "predictable outcome."
Coroner apologises to patient's family
Mr El-Cheikh, who migrated to Australia from Lebanon as a boy, had been living with diabetes, heart disease and a brain injury.
A doctor, who had reviewed Mr El-Cheikh's admission to the ICU, told the inquiry the man had the "appropriate treatment" for his sepsis and argued the patient would have died within 24-hours of presenting to hospital, "no matter how appropriate the treatment".
But Coroner Archer rejected the doctor's assertion, pointing to "demonstrated shortfalls" in his treatment that did not give the man the best chance of survival.
The findings stopped short of making findings against individual clinicians.
In summing up the inquest, Coroner Archer apologised to Mr El-Cheikh's family for the delay in the coronial and "poor levels of communication" from the court.
He also acknowledged the hospital had made some changes after the death, including updated sepsis protocols.
