Suki Thurairajah was admitted to the Canberra Hospital for haemodialysis in July 2011, but breathing complications led to the placement of a tracheal tube.

An interim finding by the coroner found the tube had been incorrectly put down the 55-year-old’s oesophagus, pushing air into her stomach instead of down her windpipe and into her lungs.

She spent 10 days in a coma before being declared officially dead.

Dr Ramsy D’Souza told the ACT Coroner’s Court on Wednesday he had experience with medical emergency teams in India, but had been given minimal training since joining the Canberra Hospital three weeks before the incident on July 29 in 2011.

“There might have been just a brief session, of around a half an hour,” he said.

As leader of the emergency team, Dr D’Souza said he was not actively involved in the intubation, but would have “stepped in immediately” if he had known that anaesthetic registrar Dr Claire-Mary Thomsett was in her first year of training.

“If I’d had an indication of the inexperience of the anaesthetic registrar, that would’ve prompted me to take over control of the airway earlier on,” he said.

Dr D’Souza also described the situation as chaotic with up to three times the “ideal number” of staff at the patient’s bedside during the incident, which left Mrs Thurairajah without oxygen for as long as 10 minutes.

“There were too many people there,” he said.

“When I arrived, there may have been 15, 18 people around the bedside.”

Dr D’Souza’s comments came after evidence from Dr Thomsett, who broke down in tears on the stand on Tuesday.

The anaesthetic registrar said she had never performed an emergency placement of the tracheal tube before July 29, when she had been called to the patient’s room via an emergency page.

Two doctors were already in the room, but Dr Thomsett said she had been forced to break with her normal practise and do multiple parts of the procedure on her own after requests for assistance weren’t responded to.

The hearing in the ACT Coroner’s Court continues.