AN inquest into the death of 46-year-old Lynette Maree Young at Dubbo Base Hospital three years ago has identified "a series of failures by the staff and the system".
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Coroner Helen Barry handed down the findings at the State Coroner's Court in Glebe this week.
Ms Young died at the hospital on April 29, 2012, less than a week after starting treatment at Dubbo Base Hospital's chemotherapy unit following surgery in Sydney to remove a melanoma.
The inquest heard the mother-of-two was "an amazing partner" and "fantastic mother" who was loving, caring, always put others first and "was very strong and determined to beat the cancer".
The inquest heard Ms Young's care at Dubbo Base Hospital was characterised in part by a "series of failures" including inadequate observations, poor recording of notes and observations, inadequate handover, a failure to recognise and respond to her deteriorating condition and a lack of trained staff to perform an echocardiogram.
In January that year Ms Young had surgery in Sydney to remove a cancerous lump from under her arm and began undergoing Interferon treatment at Dubbo Base Hospital's chemotherapy unit on April 23, 2012.
On April 28, 2012, the day before she died, Ms Young presented at Wellington Hospital with chest pain and was taken by ambulance to Dubbo Base Hospital for further investigation.
An initial examination at Dubbo indicated Ms Young may have had pericarditis (inflammation of the sac surrounding the heart).
The following day, an on-call cardiologist at Orange advised an echocardiogram should be performed.
There was no echocardiogram technician on duty at Dubbo Base Hospital during the weekend. There were plans to perform the test the next day, but Ms Young's deteriorating condition prompted a decision to transfer her to Orange on Sunday and she died before that happened.
The inquest heard "contrary to policy", Ms Young did not receive hourly vital signs observations after arriving at Dubbo's emergency department. A decision was made in the emergency department to admit Ms Young to a monitored bed but she was, in fact, admitted to an unmonitored bed in G ward on the night of April 28.
The report said no further observations of Ms Young were taken between 7.20pm on April 28 and 5am on April 29.
A review on the morning of April 29 saw Ms Young transferred to the hospital's HDU (high dependency unit) where, according to the report, the "most alarming failures took place".
It described the care provided by a nurse allocated to Ms Young's care as "grossly inadequate and of serious concern" and noted her absence from the ward for "a significant period of time" during a "crucial time" in Ms Young's care.
When the nurse "absented herself" from HDU, the report said, there appeared to have been no handover of the patient's care to another nurse.
The nurse later gave evidence, apologising to Ms Young's partner and "acknowledging her failings".
Ms Young had exhibited rapid heartbeat, temperature "in the hypothermic range", "undetectable" blood pressure, "no recorded urine output" and "severe pain" on the day of her death, the report said.
An emergency team call went out between 2.35pm and 2.50pm on April 29. Ms Young went into cardiac arrest at 3.21pm and died sometime between 4.05pm and 4.40pm.
The Coroner said differing expert opinions provided to the inquest meant she could not determine with any certainty the cause of Ms Young's death, but areas of agreement suggested it be noted as "shock following Interferon alpha treatment following the removal of a melanoma".
The report noted experts agreed treatment with Interferon alpha could have adverse effects.
Extensive changes have since been implemented to improve the system for staff and patients, the report said.
These included further training, increased intensive care unit staffing and changes to the handover procedure between shifts.
As a result of "continued lack of availability of persons trained in echocardiograms", the Coroner also recommended the hospital compile and circulate a list of personnel who had training, qualifications or experience to perform bedside ultrasound or echocardiograms, and that the hospital encourage medical staff to take up training in bedside ultrasound.
