Mr McLeod's wife and his sons Scott and Peter submitted that medical staff at the hospital failed to appreciate that a portacath inserted into the vena cava vein in his chest the year before had migrated into the wrong vein and eroded into his trachea. Dr Bain heard evidence that the catheter displacement was clearly obvious in a CT scan on August 10, 2012 and in a chest x-ray ordered by the hospital's emergency department on September 16, 2012.
Despite this, the greenlight was given by oncologist Dr Richard North to go ahead with chemotherapy on September 19, 2012. Dr North was not at the hospital at the time.
Mr McLeod complained of pain during the start of his chemo treatment.
He died at Waipuna Hospice on October 1, 2012. The pathologist concluded the primary cause of death was acute pneumonia and a chest infection.
During yesterday's inquest Dr North admitted the oncology team "missed one of these extremely rare diagnoses which we deeply regret".
He conceded that if it had not been for a nurse concerned about Mr McLeod's condition he could have been administered a highly-toxic lethal drug into his lungs.
Dr North said he did not routinely look at chest x-rays ordered by doctors in other departments, and unless they were forwarded to him he would not necessarily know about it.
"Clearly in this case the oncology team missed one of these extremely rare diagnoses which we deeply regret. However, once obvious it was acted on immediately.
"I am confident that I and my team provided the best care possible to Mr McLeod and his family.
"Alas it was not enough. I want you to know that we did care and loved Curly, he was a good mate."
Dr North said following a major case review , the protocol for portacath infusions had been changed. Radiologists are also required to comment on the placement of catheters after every x-ray and any significant abnormal placements flagged in the hospital's electronic reporting system, he said.
Dr Wallace Bain adjourned the hearing, and called for written submissions from the McLeods' lawyer, and the DHB's governance and quality general manager Gail Bingham.
Recommendations
The McLeod's medical experts Dr Hilary Blacklock and Dr David Milne recommended:
*Hospital standard operating procedures be made available for use of intravenous and central lines to deliver drugs, especially chemotherapy.
*More standardised template reports be used by radiologists to ensure that all aspects of an x-ray, ultra-sound or CT scan get reported.
*Phrases such as "position is unchanged'' be avoided.
*All unwell patients be medically assessed before each course of chemotherapy.
