A man died because he was given another patient's medication following a routine knee surgery, the NSW Coroner's Court has heard.
Father-of-two Paul Lau passed away from an overdose several hours after an operation at Macquarie University Hospital in 2015.
Counsel assisting the inquest, Kirsten Edwards, claimed there were 15 missed opportunities for medical practitioners to spot the fatal error and save Mr Lau's life.
"These sorts of deaths just shouldn't happen in a modern, advanced, medical facility," ABC News quoted Ms Edwards as saying.
The hospital had installed a new computer system for prescribing medicine one month prior to Mr Lau's death.
Anaesthetist Dr Orison Kim mistakenly inputted the drug information for another patient, who required far stronger medication, into Mr Lau's electronic chart. The anaesthetist later admitted he had not received any formal training to use the new system and failed to seek the necessary skills.
No medical practitioners questioned the chart in the hours after the surgery, despite several nurses and Dr Kim attending Mr Lau during that time.
The patient's son, Johnathan Lau, told reporters outside the Coroner's Court that no single employee could be blamed for the incident due to the number of professionals who had missed the error.
"Hopefully nothing like this happens again. Systems need to be in place, guidelines need to be standardised [and] having everyone get proper training would be preferable," he added.
Medical practitioners have a duty of care to ensure their patient's safety and wellbeing.
People who suffer serious injuries when receiving treatment may be entitled to compensation when doctors and nurses fail to meet expected standards of professionalism. In cases where a patient dies, their family may be awarded damages instead.
While it is not clear whether compensation was sought or awarded to Mr Lau's family, a medical error of this magnitude could very well constitute negligence given the circumstances.
In fact, medication mix-ups are the only situations to date under which doctors have been successfully convicted of medical manslaughter charges in Australia. However, this does not appear to be the case here.
"People involved in the care of Paul have been responsible and accepted they made mistakes," said Ms Edwards.
The hospital has also changed various procedures in an effort to prevent similar mistakes in the future.
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