CANBERRA woman Hue Le was bloodied and bruised after she was bashed at a playground in Kaleen in 2005, but she was not expected to die.
While her face was swollen and and some of her teeth had been knocked out in a suburban dispute over which her attackers were later charged, medical experts found her injuries were not life-threatening.
But just days after entering an emergency department she was dead, and eight years later her two children still do not know the official reason why.
Hue Le's case is one of more than 20 ACT coronial inquests dating as far back as 2005 that are still unresolved.
Medico-legal documents suggest septic shock killed Ms Le, probably because Canberra Hospital staff stuck an infectious cannula (fluid tube) into her arm.
The Canberra Times reported last month that hundreds of Australians a year die or have limbs amputated because of infections contracted in hospitals.
But Ms Le's family has no way of knowing for sure if she was one of them, and have pleaded with the court to finally give them closure.
The ACT Coroner is yet to make a finding on her death five years after an inquest was opened that could potentially identify problems in the health system, and more than seven years after she died.
''Two little kids lost their mum - why don't we have any answers yet?'' asked family member Marion Le.
''We don't even have a death certificate for her.''
President of the ACT Bar Association Greg Stretton said: ''The delay in the Hue Le inquest of five years to date is simply unacceptable and a blot on the justice system." Coroners Court figures show 23 cases started between 2005 and 2010 are still outstanding.
Responsibility for the Hue Le matter transferred to Peter Dingwall, who is now on extended sick leave, when Coroner Ron Cahill retired.
Hue Le was 36 when she died in Canberra Hospital, and her children were still in primary school.
Tests showed golden staph was at one point found on the cannula inserted into Ms Le's body, according to documents relating to the investigation into her death. While some medical experts speculated that Ms Le may have been a drug user, which may have exposed her to infection before going to hospital, this was disputed by the dead woman's GP and family.
The family alleged the hospital missed the fact Ms Le was a long-time sufferer from lupus, which reduces the body's ability to fight infections.
Golden staph is a common and potentially dangerous infection found in hospitals.
One of the biggest infection causes is staff not washing their hands properly.
Canberra Hospital staff failed to meet the national benchmark for hand hygiene in four out of five of its audits in the 18 months to March this year.
The hospital's estimated rate of correct hand hygiene hovered at about 65 per cent during these periods and only once did it exceed the 70 per cent benchmark, in June last year.
The latest figures show 57 patients had golden staph in their bloodstream at Canberra Hospital in the two years to June last year.
Amputee Brendan Morrison said he caught a staph infection at the hospital. Mr Morrison, 58, said he had toes cut from his foot and his leg got golden staph while he was being treated as an outpatient at Canberra Hospital.
He said the leg was cut off five months later.
There have been multiple catastrophic consequences because of infections caught by patients at territory hospitals.
A spokeswoman for ACT Health said the directorate had a comprehensive infection prevention and control service.
''ACT Health has been fully accredited with the Australian Council on Healthcare Standards,'' the spokeswoman said.
''ACT Health received a rating of extensive achievement.''
Fairfax Media revealed last month that three ACT women had needed legs amputated in recent years after they caught infections during or after apparently simple knee replacements.
Two of the patients were at Calvary Private Hospital while the third was at Calvary Public.
There is a coronial inquest under way into the death of another woman, Suzanne Smart, after she caught a flesh-eating infection and had her bowel punctured at Calvary Public Hospital.