The chief coroner has cleared medical staff of any wrongdoing in the death of a cancer patient who had a heart attack during surgery at the Canberra Hospital.
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Hubert Jansen, 67, first began to feel unusually ill in September 2011, complaining of flu-like symptoms.
It was a strange turn for Mr Jansen, who was an otherwise happy, healthy, fit man who had taken just five sick days in his entire life.
He went to his doctor, who suspected pneumonia and gave him antibiotics.
It wasn't clear then to anyone, but Mr Jansen's kidney was wracked with cancer, and he had significant underlying problems with his heart.
He deteriorated further, losing weight, and continuing to experience flu-like symptoms. He went to the Goulburn Base Hospital, but was discharged again with antibiotics.
Mr Jansen soon began suffering abdominal pain and returned to hospital, where a CT scan revealed a large mass on his left kidney, while a chest X-ray showed an enlarged heart and problems with his left lung.
Doctors at Goulburn called Canberra Hospital for advice, as is standard practice, but it took 12 days for them to eventually find a bed and transfer Mr Jansen to the ACT.
He underwent surgery four days after his arrival in Canberra.
But, as Chief Coroner Lorraine Walker said on Friday, Mr Jansen's body could simply not take the strain of the procedure.
He went into cardiac arrest during the four-hour surgery, was resuscitated, and underwent further procedures.
Mr Jansen never recovered, and passed away in hospital.
The case was referred to the ACT Coroners Court because he passed away within 24 hours of the surgery.
The inquest examined whether Jansen should have been transferred to Canberra sooner, and whether there were any issues with his treatment.
Ms Walker delivered her findings on Friday, expressing her condolences to Mr Jansen's wife, who was in court, and acknowledging the difficulty she must be facing in dealing with the loss.
But she said she found no evidence arising out of Mr Jansen's treatment requiring her to make adverse findings or recommendations.
The cancer, she said, was likely present for months before he first saw the doctor, and Mr Jansen was also suffering from significant underlying diseases.
She said his case was urgent, but not the "most urgent", and there was nothing available to treating doctors that warranted an urgent transfer to Canberra Hospital.
It was unlikely he would have received any different treatment in the ACT, she said, and it was unlikely events would have developed any differently.
The risk to his life from surgery, Ms Walker said, was present from the moment he was first diagnosed.
Ms Walker said it was unsurprising that his body was unable to deal with the strain of the procedure.
"The situation was an impossible one," she said.
The court found no matters of public safety arising from the case, and Ms Walker said she was mindful that processes around hospital transfers not be over-regulated, to allow medical teams to make the best decisions they could.
