Mistakes that left a dialysis patient brain dead at the Canberra Hospital do not pose an ongoing risk to public safety, the ACT coroner has found.
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Suki Thurairajah, 55, was admitted to the hospital July 2011 for haemodialysis.
She reacted badly to the treatment, prompting breathing difficulties.
Medical staff were forced to insert a tracheal tube to assist with airway management.
But the tube was placed incorrectly, most likely initially inserted into her oesophagus instead of her windpipe and lungs.
ACT Chief Coroner Lorraine Walker found the mistake "significantly contributed" to the inability to get oxygen into her lungs in a timely manner.
Mrs Thurairajah suffered significant neurological damage during the period she was without oxygen.
She remained in a coma for 10 days, and the family were told that she had little chance of recovering.
The family made the decision to stop life support, and Mrs Thurairajah died shortly after.
The death was referred to the coroner, and Ms Walker delivered her findings on Monday morning.
Ms Walker found the care of Mrs Thurairajah to be "less than perfect".
She described the scene as chaotic, noisy, and complicated by a large number of staff - 12 to 18 in total.
There was also found to be a lack of management by the medical emergency treatment team's leader, who did not have the experience to confidently assert himself and assign tasks to others.
The medical officer tasked with placing the tube was new, and had no experience in performing the task in an emergency situation.
Mrs Thurairajah's large jaw and neck, combined with her vomiting, made it difficult to insert the tube. The team also failed to realise their mistake for a range of reasons, including that the environment was chaotic, there was poor communication, and staff were distracted to signs that could have told them something was wrong.
There was also a delay in using a carbon monoxide monitor that was on the medical emergency team's tray, which could have told them something was wrong.
Ms Walker found the team had a lack of familiarity with the machine, which was described as the "gold standard" for such monitoring.
There was also a delay while staff waited for that machine to warm up and calibrate, and also to recognise the absence of wave forms, which should have suggested the tube wasn't placed properly.
Mrs Thurairajah's prognosis was not great before the mistaken placement of the tube, and she had already suffered breathing difficulties.
Despite the problems with the treatment, Ms Walker did not find cause for ongoing concern for public safety.
She said no one in particular was in fault, and the mistakes were not part of systemic problems.
Improvements had since been made at the hospital, including the introduction of a new carbon monoxide monitor that did not require warm up, and a trolley checklist to be completed by medical emergency teams.
Ms Walker did make some limited recommendations, including that the hospital require all medical emergency team staff to sign a form saying they had read and were familiar with relevant policies and equipment every year.
She also recommended that individual team members identify themselves during such emergencies, state their role, their level of experience, and ask who was in charge.
Ms Walker expressed her condolences to the family of Mrs Thurairajah, who were in court.
