Brooke Tiddy was admitted to St George Private Hospital in Sydney on September 18, 2018 for elective bariatric surgery recommended by her doctor, who assessed her as "super super obese".
But the surgery was abandoned after complications arose when medical practitioners attempted to administer anaesthesia.
Before Ms Tiddy died in the early hours of September 21 of a cardiac arrest, her last words to her family were "I want to go home".
At an inquest into her death, her loving family remembered the 32-year-old as a caring, cheeky and funny woman whose unexpected death left them reeling.
"It was extremely hard to accept that she went in for surgery and would not be coming home," the family wrote in an emotional statement.
"Although it's been seven years, the pain never ends and Brooke will never be forgotten."
Coroner Stuart Devine found here were multiple missed opportunities in Ms Tiddy's preparation for surgery, including inadequate pre-operative assessments from her surgeon and anaesthetist.
Ms Tiddy lived with sponastrime dysplasia, which affects the muscles and skeletal system.
One of the associated features is a narrowing of the airways which was ultimately found to have contributed to Ms Tiddy's death.
Her would-be surgeon Vytauras Kuzinkovas - who, like many experts, had not previously heard of the condition - did not make adequate attempts to understand it, the coroner concluded.
Mr Devine said the highly unusual condition meant Dr Kuzinkovas should have taken reasonable steps to have Ms Tiddy examined more closely before she was admitted to hospital.
The lack of communication between the surgeon and anaesthetist Vincent Da Silva was another lost opportunity for investigation into the condition and to make an informed decision about proceeding with the surgery, the coroner found.
He made four recommendations, including that St George Private Hospital review and potentially amend its policies around admissions, anaesthetics and compromised airway intubation.
The hospital has already begun to make changes, including implementing a requirement that patients such as Ms Tiddy undergo an intensive diagnostic study and changing the nurse-to-nurse handover policy.
Mr Devine said he was satisfied the hospital had reflected on the contributing factors of Ms Tiddy's death and made improvements to ensure what happened is not repeated.
Without accepting he contributed to Ms Tiddy's death, Dr Kuzinkovas told the court he acknowledged her family's grief and said he has implemented changes in his practice.
Dr Da Silva has also made changes after reflecting on the death and learning some difficult lessons, he told the inquest.
Ms Tiddy's family wiped away tears as the findings were handed down in Lidcombe Coroners Court late last year.
Outside, her sister Julie Cox said they were happy with the coroner's findings and they hoped the hospital would implement the suggestions.
"We hope this will prevent anyone else going through what we've gone through," she said.
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