The hospital's treatment of Maxine Fulton, 68, came under close scrutiny this week in the ACT Coroner's Court, where an inquest is exploring whether systemic failings were involved in her death.

Mrs Fulton was being treated for tongue cancer in late 2013, when a decision was made to extract four of her teeth before planned radiation therapy, a common and technically simple surgery in most cases.

Mrs Fulton's case, however, was far from typical.

She had a large, growing tumour on her tongue. The patient was anxious, she was frail, had a complex medical history, and a range of co-morbidities.

The significant danger was always that medical teams would not be able to keep her airway clear, particularly with the added risk of having her under anaesthetic or sedation.

Yet, those fears were allowed to eventuate during a high-risk operation that has come under fire from a leading anaesthetist and eminent surgeon.

Mrs Fulton's breathing was obstructed and she suffered a cardiac arrest, and, although resuscitated, did not fully recover. Mrs Fulton died days later.

The first of two operations took place late on the afternoon of December 10, 2013. Mrs Fulton was put under a general anaesthetic, and doctors tried four times to secure an open airway through intubation but failed, and were forced to abort the procedure.

It was the next series of decisions that has been put under the spotlight in the inquest.

Wary of the looming Christmas shutdown of elective surgery lists and Mrs Fulton's pressing need for radiation therapy, the hospital decided to rush her into surgery again the next morning, about 9.30am on December 11.

There appears to have been little communication to Mrs Fulton about the risks of breathing obstructions.

She was given little time to think about it or talk it through with her family, even though the second operation was likely to pose an even greater risk.

That is something that troubled Chief Coroner Lorraine Walker, who asked Mrs Fulton's senior surgeon on Wednesday:

"We have a lady who's having her teeth extracted ... and no one seems to have pointed out to her that she was a risk of dying during surgery," Ms Walker said.

"Isn't that someone's responsibility?"

One of Australia's most eminent surgeons, Professor Alastair Goss, told the inquest the second surgery was a "high-risk call with a high chance" of what would eventuate.

Professor Goss said the operation should simply not have taken place and that it was an "error of judgment".

"On the 11th, I wouldn't have done it, or recommended it, or anything else," he said.

The failed intubation the day before would have irritated the tumour, he said, probably causing swelling, leaving blood, and creating more chance of obstruction.

Mrs Fulton was laid flat on her back because her medical team believed other positions were impractical for the surgery.

Lying on one's back, Professor Goss said, was the worst possible position for maintaining an open airway in cases such as Mrs Fulton's.

It was decided Mrs Fulton would be given a combination of local anaesthetic and sedation, in an attempt by doctors to relieve the pain, but also deal with her anxiety, which can make such a procedure dangerous.

A leading anaesthetist, Dr Keith Greenland, told the inquest that combination was high risk, and Professor Goss said it "clearly was the procedure with the highest chance of a negative outcome".

Dr Greenland said he would not have used it in Mrs Fulton's case, where airway management was so crucial.

"It doesn't take much to fall off and that's what happened," he said.

Instead, Dr Greenland told the inquest that doctors should not have rushed her into it without proper explanation of the risks.

He said he would have waited at least a week before trying again, this time keeping her awake and using a fibre-optic intubation.

"The system is failing her with what she needs, which is a slower pace and more communication," he said.

Professor Goss said he would have allowed the radiation therapy to occur before the teeth extraction.

A crucial point being explored in the inquest is the lack of communication between the anaesthetists, who have responsibility for airway management, and the surgeons.

There have been suggestions that surgeons and anaesthetists operated in two separate tribes, rather than together as a team.

The inquest is also considering why the ACT does not require patients to give separate consent for the surgery and anaesthesia, something that would effectively require the patient be informed of, and acquiesce to, the risks associated with each.

Professor Goss said the ACT appeared to be behind other jurisdictions in that respect, saying separate consent has been obtained in his home state of South Australia for "as long as I can remember".

"If there is a silver lining out of this situation, perhaps the ACT needs to catch up with South Australia," he said.

Ms Walker has reserved her findings, and expects to hand them down in June.