TASMANIA'S health system failed a Deloraine man who died just hours after being discharged from the Launceston General Hospital, an inquest heard yesterday.
Donald John Clarke, 40, died from a respiratory- related illness on July 24, 2011.
In an emotional day for his family, Mr Clarke's wife, Nicole, broke down in Launceston Coroner's Court as she recounted the days leading up to his death.
Mr Clarke, a Meander Valley Council worker, had undergone neck surgery at St Luke's Private Hospital 10 days before dying.
In the days following his release, Mr Clarke went to a local GP complaining of difficulty swallowing and breathing, his wife said.
The symptoms worsened that night and he developed hallucinations, prompting the family to call an ambulance.
"I knew something was wrong," Mrs Clarke said.
Mr Clarke was taken to the LGH emergency department, where his wife raised concerns about his breathing, the inquest heard.
However, he was discharged that afternoon, following three CT scans, with doctors linking the hallucinations to his medication.
He was found dead by his wife the following morning.
An autopsy revealed aspiration pneumonia as the primary cause.
Yesterday the LGH's orthopaedic registrar who saw Mr Clarke before his release said the patient was a victim of "system failure".
"The emergency department was extremely understaffed that day," Dr Yi Yang said.
Dr Yang said he failed to diagnose potentially fatal swelling in Mr Clarke's neck due to inexperience.
He told Ms Clarke's counsel, Chris Bartlett, that the patient "absolutely" should have been admitted to the intensive care unit to have "his airway secured".
It was problematic that Mr Clarke was sent home on the same amount of opioids - which depress the respiratory system - that he came in with, Dr Yang said.
He told the inquest that at the time his "airway training" was limited to being familiar with CPR.
The inquest, before coroner Rod Chandler, continues today.