Calvary Hospital has been cleared of blame in the death almost 10 years ago of a severely disabled Canberra man who died just hours after being sent home from the north side hospital.
But the epic coronial process - that took evidence from nine medical experts and generated 800 pages of court transcripts - has already changed the way the city's medical services treat people with high and complex needs.
Stephen Moon died at his Narrabundah home on December 15, 2003, the same day the hospital had discharged him after he spent three days in intensive care under sedation.
The 21-year-old suffered from autism, an intellectual disability, was prone to violence and needed around-the-clock care.
Mr Moon, who could not talk and communicated in sign language, had his four wisdom teeth removed under general anaesthetic on December 12.
A ''root cause analysis" of the tragedy by Disability ACT resulted in an overhaul of procedures for the care of severely disabled people having serious procedures in the city's hospitals.
Training manuals, treatment plans, consultation with carers and families before admission and discharge are now all standard across the health service.
But the suggestion of a stand-alone facility to treat patients with needs similar to Mr Moon's has been judged impractical for such a small group of patients.
In his response to eight recommendations from Coroner Peter Dingwall, Attorney-General Simon Corbell said hospital admissions for severely disabled people were planned well in advance.
"Admissions for special care patients are organised well in advance and involve all relevant stakeholders," Mr Corbell said.
A hearing in 2006 heard Mr Moon's carers had been concerned their patient could react violently to post-surgery pain, and doctors had agreed to sedate him for up to seven days until the pain had
subsided. Due to a quicker-than-expected recovery, he had been discharged after three days, and prescribed antibiotics for what doctors said was a mild case of pneumonia.
The 2006 inquest heard Mr Moon's carers had agreed to take over his pain management upon discharge, and had arranged a post-surgery phone check-up.
But phone calls from the hospital that day went unanswered, and Mr Moon died soon after.
Mr Moon's carers had said he had been frothing at the mouth shortly before he died, and attempts to resuscitate him had been hampered because his mouth would fill up with red liquid - believed to contain blood - every time they opened his mouth.
In his findings, tabled in the Legislative Assembly this week, Mr Dingwall found that discharging Mr Moon to the care of his non-medical disability workers after he had been sedated for three days, was unorthodox but did not contribute to the young man's death.
"In spite of the fact that the discharge arrangements for Stephen were unorthodox, that [there] is no evidence of any failure on the part of Cavalry in its responsibility and care towards Stephen nor was it causative to his death," Mr Dingwall wrote.