A hospital misled a health safety watchdog and blamed a woman and her family for pressuring its surgeon into performing a deadly operation.
Cherie Guest, 61, would still be alive today if an eye surgeon had not operated on her while she was struggling to breathe, a Victorian coroner found on Thursday.
But the day clinic where she was operated on, Victoria Parade Surgery Centre, misled a Safer Care Victoria review and said Mrs Guest and her daughter Angela had pushed for the surgery.
"These statements were patently wrong," coroner Katherine Lorenz said.
All evidence, including that of eye surgeon Joseph San Laureano, proved Mrs Guest and her family had begged for her not to undergo the surgery.
Ms Lorenz said the hospital's review document misled Safer Care Victoria, which acts to ensure deaths likes Mrs Guest's are avoided.
Her family said the document was "abhorrent" and a cover-up.
"It’s morally reprehensible for someone to blame someone who has died for that death, when part of the reason for that is their own procedures," Angela Guest said outside court.
It was the responsibility of three medical professionals to cancel Mrs Guest's surgery after red flags were raised over her respiratory issues, the coroner said in finding her death was preventable.
She visited Dr San Laureano's for a diabetic eye check in July 2018, after being referred by her GP, and he recommended cataract surgery.
But Mrs Guest, who had several pre-existing health conditions, told the surgeon she could not lie down flat for long due to breathing issues.
She relied on a home oxygen tank to breathe and used a wheelchair.
Dr San Laureano decided to perform a two-part operation using a laser machine for the first, instead of conventional cataract surgery.
After the consultation, Mrs Guest and her daughter were concerned and called VPSC to request a trial run.
The trial was not conducted by Dr San Laureano but by his employee.
He was told it was successful and made no further inquiries, deciding to go ahead with the surgery.
Other hospital staff said they were astounded and alarmed surgery would continue despite Mrs Guest's severe breathing difficulties.
After the first operation, on August 18, Mrs Guest's lips began turning blue, oxygen levels dropped to 60 per cent and her heart rate was high.
Mrs Guest and her daughter asked Dr San Laureano not to go through with the second procedure, but he continued anyway.
Her breathing deteriorated and she pleaded to sit up, but Dr San Laureano said he had to continue or she could lose an eye.
She died after being taken to St Vincent’s Hospital by ambulance.
The coroner found Mrs Guest should have been assessed by a multi-disciplinary team, including her respiratory specialists, before surgery.
If surgery was to proceed, it should have been performed at a hospital with critical care facilities.
Hospital chief executive Timothy Puyk, who knew Mrs Guest was high-risk, should not have allowed the surgery to go ahead.
Dr San Laureano failed to conduct his own assessment of Mrs Guest's suitability and failed to act on information available to him that she was unfit, falling short of ophthalmology standards.
Anaesthetist Fabian Purcell, who was present for the second procedure, had already raised concerns about her breathing and was also obliged to have the surgery cancelled.
Further, Mrs Guest was given no choice but for the surgery to go ahead and was given Xylocaine, a local anaesthetic she was allergic to.
Mrs Guest's family intend to pursue a court claim for loss and injury caused by her death.
