A coronial inquest into the death of an Oaklands man has heard the doctor who conducted a failed bowel operation on him felt "out of her depth" in seeking to address her surgical error.
William Edmunds, 79, died in the intensive care unit at Albury Base Hospital on December 2, 2019 from complications of peritonitis following the error.
About a month earlier, Dr Liu-Ming Schmidt had performed a Hartmann's procedure on Mr Edmunds, which involved removing a large piece of his bowel.
The inquest heard that Dr Schmidt performed the surgery on the wrong end of Mr Edmunds' colon — the distal end.
During Friday's inquest proceedings, counsel assisting the coroner Matthew Robinson asked Dr Schmidt whether she was the primary surgeon for Mr Edmunds when a second operation on him took place on November 15, 2019 — the same day the surgical error had been identified and eight days after the failed surgery occurred.
Dr Schmidt said she had been the primary surgeon that day but that Dr Ajay John, a VMO general surgeon at Albury/Wodonga Health, had supervised her.
"I was completely guided by Dr John and his expertise … [and] was very grateful that he came to help me," she said.
"I made a significant error and I was not in the right frame of mind … I was out of my depth."
Mr Robinson asked her if she needed a supervisor in relation to the matter.
"I do, once I made a mistake," she said.
"As you can imagine, I felt … devastated and I deferred to Dr John for his expertise."
'I had limited time'
During Thursday's proceedings, Dr Schmidt apologised to Mr Edmunds' children, Wade and Sue, about the error and said she was "very, very sorry" for what had happened.
She also confirmed she had only performed a Hartmann's procedure once in the five years prior to Mr Edmunds' initial surgery.
Mr Robinson asked Dr Schmidt whether the surgical error had been made because of her lack of experience in colorectal surgery.
"That certainly contributed to that," she said.
"You could have traced or followed the bowel?" he asked.
"If you could just be there with me looking at bowel [then it was] impossible to trace as such without putting other important structures at risk," she said.
"I had limited time [and a] very sick patient on my table.
"That was my judgement and decision on the day [about] what was best for Mr Edmunds."
Procedure like 'riding a bike'
The inquest has also heard from a number of doctors this week with various concerns highlighted, such as increasing levels of fentanyl for Mr Edmunds' pain relief following the first operation, the time taken to request an abdominal CT scan after that, and the time taken to consider a mechanical bowel obstruction for Mr Edmunds.
Dr John Stuchbery, the director of surgery at Albury/Wodonga Health, told the inquest on Wednesday that Mr Edmunds' procedure should have been straightforward.
"Doing a Hartmann's procedure is a bit like riding a bike. It's a routine operation," he said.
"It ought to be carried out appropriately by a general surgeon."
Dr Schmidt said she disagreed with that characterisation during Friday's proceedings.
"It's not routine for me anyway," she said.
"I wouldn't call it simple."
Concerns regarding communication
This week's proceedings also heard concerns about the way in which Dr Schmidt discussed matters with Mr Edmunds and his family following his first operation.
On Wednesday, the inquest heard from two nurses at the hospital who said they were present — although did not hear all of the conversation — when Dr Schmidt spoke to Mr Edmunds on November 15, 2019 about what would happen next.
Both of them told the inquest that Dr Schmidt had not delivered an "open disclosure" to Mr Edmunds when she spoke with him — a process that involves speaking to a patient, their family, and carers about an incident that causes harm while receiving health care, as well as a formal apology or expression of regret for that incident.
Mr Robinson asked Dr Schmidt about the matter during Friday's proceedings.
"I thought at the time I had [given an open disclosure]," she said.
"But hearing the evidence I admit I clearly failed in giving an open disclosure."
The inquest also heard that none of Mr Edmunds' family members were present during that initial discussion.
Dr Schmidt said she had contacted Wade Edmunds before the surgery that day, but that she was not sure whether she had left a voice message or spoken to him.
Wade Edmunds told the inquest he did not receive a call or message from her that day.
The inquest before deputy state coroner Erin Kennedy is expected to resume in Sydney in March 2023.
