A lung sample taken from Broken Hill man Dennis Jackson could have been contaminated with the sample of another patient, an inquest into his death has heard.
Mr Jackson was 67 when he died on January 21, 2019, just months after he underwent an "unnecessary left upper lobectomy" in August 2018.
A lobectomy is the removal of part of or all of a lung.
Counsel assisting the coroner, Emma Roper, started her closing comments by saying Mr Jackson died after a series of mistakes were made.
"His death followed a lengthy and by all accounts miserable stay in the intensive care unit where extensive but unsuccessful attempts were made to prevent his respiratory decline," she said.
"It is my submission that the unnecessary surgery occurred due to an erroneous diagnosis of squamous cell carcinoma of the lung."
Potential contamination
The inquest heard a sample of Mr Jackson's lung was extracted and examined just before 1pm on July 25, 2018.
The specimen was sent to SA Pathology where testing was carried out overnight and delivered at 2:55pm on July 26.
Ms Roper said there was a strong possibility the forceps used to extract the sample from Mr Jackson was the same instrument used to extract a sample from another patient.
Ms Roper said there was a chance the forceps were not cleaned properly, leading to cross-contamination.
She said the other patient's specimen returned a cancerous diagnosis.
"It can be inferred that one of the three fragments of this patient's biopsy sample was absent from the slides examined by the reporting pathologist in this case, that fragment having remained on the embedded forceps," she said.
"That patient's results were reported on July 26, the same day as Mr Jackson's results.
"From that report you will see that this patient received a diagnosis of at least in situ squamous cell carcinoma."
Call for review
Ms Roper finished her closing statements in the Coroners Court of South Australia on Thursday last week with a series of recommendations to Deputy State Coroner Ian White.
"The death of Mr Jackson was, in my submission, a preventable one," she said.
"It would not have occurred but for the contamination event that occurred during the early hours of 26 July, 2018."
She recommended the Minister for Health and Wellbeing engage an external scientist to conduct an independent review of SA Pathology's anatomical pathology laboratories.
She also suggested a set of guidelines be made to better monitor potential cases of contamination.
Mr White said there was a strong indication the forceps used to handle Mr Jackson's specimen were likely contaminated.
"I think that circumstantial evidence is close to overwhelming, that that must be what happened," he said.
He said the flaming of forceps could be a practice taken into consideration to properly clean the items.
Mr White closed the inquest by thanking those who had taken part.
"Thank you all, counsel, for this really sad situation that's affected the Jackson family and the medicos involved so deeply," he said.
No date has been listed for the findings into Mr Jackson's death to be delivered.
