Paul Harris died at Hay District Hospital, in the NSW Riverina, on October 17, 2019, after being treated for a suspected case of community-acquired pneumonia.
An inquest heard the 43-year-old Indigenous meat worker also had Q fever and a blood clot in the lungs, but both went undiagnosed at the rural facility.
Q fever is a disease caused by bacteria, generally spread to humans from livestock.
Mr Harris was admitted to hospital in late September 2019 with pneumonia and was discharged after responding to antibiotics.
But on October 9, he returned to the town’s medical centre saying he’d coughed up blood and a doctor who worked in both the clinic and the hospital re-admitted him.
The doctor initially considered the possibility of a lung clot, but further examinations at the hospital led him to believe recurrent pneumonia was more likely.
He said he did not test for Q fever because the antibiotics used to treat pneumonia would manage both conditions.
Five days later, Mr Harris's health was not improving and the doctor ordered more tests, but did not transfer him to the larger hospital at Griffith for a specialised scan.
Expert reports provided to the inquest said his care should have been escalated and two doctors at Hay Hospital acted on “most likely” scenarios, rather than ruling out serious conditions.
Deputy State Coroner Rebecca Hosking on Tuesday, January 13 found Mr Harris should have been transferred to the Griffith facility for a CT angiogram on his lungs.
But she was unable to rule whether earlier detection of the clot would have saved Mr Harris's life.
Given his work in a kangaroo meat processing plant, Mr Harris's risk of Q fever also should have been identified earlier, Ms Hosking found.
She acknowledged that the antibiotics for pneumonia would have treated both conditions.
Evidence from specialists presented to the inquest said there was a connection between Q fever and clots, but it was not widely known.
The coroner said she was unable to rule on the origin of the clot, nor whether Q fever contributed to Mr Harris's death.
Ms Hosking recommended the Murrumbidgee Local Health District provide training to its staff to strengthen relationships between hospitals in the region.
She offered her condolences to the family of Mr Harris, a loved father and step-father to five adult children.
“He had a big personality, and was described by his family as a larrikin, who enjoyed making people laugh,” she told Lidcombe Coroners Court.
“His family has suffered a great loss felt every day, but particularly when he’s not there to share their significant milestones.”
– with AAP
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