Like many people last winter, 55-year-old Melbourne woman Anna Civitico developed a sore throat and a headache.
Within a month, she was dead.
Her husband Danny has been left in grief, shock and searching for answers.
"How did we get from a perfectly fit woman, strong as a mallee bull, you know, and full of love and compassion for everyone else ... how does that person's life end up just horribly like that?" Mr Civitico said.
The former police officer believes his wife would still be here if not for a string of failures made by the two Melbourne hospitals that treated her.
"I would hate to think that anyone else would have to go through what we do. We hope that the hospitals do their due diligence, and they do everything correctly and properly and deal with patients," he said.
"That they look after them, treat them and they come home safe to their loved ones. That's what I would hope."
How it happened
By mid-July, Anna Civitico's throat pain and headaches were so bad she went to the Royal Melbourne Hospital.
She couldn't open her mouth more than a couple of centimetres, and her tongue was so swollen her throat couldn't be examined.
She was diagnosed with a likely viral illness but was later found to have a bacterial infection in her salivary gland.
The lawyer representing her family, Daniel Opare from Shine Lawyers, says this was a significant misdiagnosis.
"We say that if she had been given antibiotics during her first presentation, it's likely that she would have made an uneventful recovery," Mr Opare said.
She was sent home from hospital, but by the middle of the night the pain had intensified, and Ms Civitico couldn't open her mouth more than a centimetre.
This time she went to the emergency department at the Epworth, a private hospital across town.
Mr Opare says she was again misdiagnosed, this time with pharyngitis.
"Again, that's very different to a bacterial infection," he said.
"So she's given antibiotics, but they're antibiotics that are designed for pharyngitis. And they're not active against the type of infection that she actually had. So she's given those antibiotics, and then she's sent home."
Three days later, the pain had gotten so bad Ms Civitico couldn't take her medication.
She was admitted to the Epworth and a CT scan found she had a swollen salivary gland. She was given antibiotics intravenously and steroids. Four days later, she was discharged.
Her husband was shocked that she was sent home.
"They gave her a whole heap of painkillers and she still couldn't open her jaw and talk, you know, so I thought, 'what's going on here when someone doesn't look any better when they come out?'" Mr Civitico said.
He says she got progressively worse at home.
"She woke up and I looked at her face and it looked absolutely terrible. And I said, 'Bugger this, we're going straight in and ... I want them to fix it up now'.
"And she looked at me, she said, 'Am I going to die?' And I said, 'No, of course not. You will be fine, you know, they'll fix you up.'"
Ten days after she first went to hospital, Ms Civitico went back to the Epworth with worsening symptoms.
A CT scan identified an abscess and she was booked for surgery to drain it the following day.
"As far as I was concerned it was a routine operation. Nothing untoward, something that probably gets done quite a fair bit, I would imagine, and that we should be coming home," Mr Civitico said.
But the surgery didn't go to plan.
A tube became dislodged, she lost oxygen to her brain and went into cardiac arrest.
Ms Civitico was admitted to the intensive care unit in a coma. She never woke up.
Coroner findings
Last month an investigation by the coroner found the medical care leading up to Ms Civitico's final admission for surgery likely had no influence on the outcome and that her death was an unfortunate but recognised complication in a high-risk situation.
Despite that finding, Mr Civitico is now taking legal action against the hospitals.
His lawyer Daniel Opare says it's a heartbreaking case.
"We believe that Anna's death should not have occurred, and that it was due to poor medical care," Mr Opare said.
"We have very strong expert evidence which says that this was not some freak accident. And this death was due to negligence on the part of hospital staff."
In a statement to 7.30, the Royal Melbourne Hospital offered condolences to Anna Civitico's family and said it would cooperate with a review into her death.
The Epworth's chief medical officer said he was unable to comment on individual patients, but the hospital had a long-standing process to review clinical incidents to address any concerns from patients and their families.
Mr Civitico says he's not satisfied with the answers from the hospitals and wants justice for his wife of 27 years.
"I miss the hugs and the kisses and everything like that, obviously the closeness, togetherness, life together, doing things together, going out for trips, having a laugh, having a cry, all that stuff," he said.
"I don't have it anymore."
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