A MAN who died hours after leaving the Launceston General Hospital was a ``high-risk patient'' who should never have been discharged, two doctors have told an inquest.
It comes after day one of the inquest heard Donald John Clarke, 40, was a victim of ``system failure'' at the LGH.
The Deloraine resident was admitted to the LGH 10 days after undergoing neck surgery at St Luke's Private Hospital.
The surgery seemingly went smoothly but days after his release he formed difficulties breathing and swallowing and developed hallucinations.
In the early hours of July 23, 2011, his wife called an ambulance after he developed hallucinations.
On route to the LGH paramedics recorded Mr Clarke's temperature as 38 degrees.
However, according to Dr Linda Chow, who was in charge of the LGH's emergency department that day, the information was not passed on.
``Unfortunately in this case we didn't have the ambulance form with us and were not told his temperature was 38 degrees,'' she told the inquest in Launceston yesterday.
Dr Chow said the high temperature, which subsided before Mr Clarke arrived at the LGH, made him a ``high-risk patient'' who should have been admitted overnight.
Instead he was discharged that afternoon, although who by is not clear, and died sometime in the early hours of the following morning.
An autopsy found aspiration pneumonia, indicating a closure of the airways, as the cause.
Dr Chow said better communication between ``the in-patient unit and and the emergency department'' was needed at the LGH.
Poor communication has arisen several times during the inquest before coroner Rod Chandler.
Dr Chow said at no time was the emergency department told Mr Clarke had an airway obstruction.
This factor alone would have kept Mr Clarke hospitalised ``because anyone who has compromised airways doesn't go home''.
However, her evidence was contradicted by radiologist Joseph Zakon, who carried out three scans on Mr Clarke and discussed them with the emergency department.
Mr Clarke's neck scan, shown in the inquest, cleary displayed a closing of his airway.
``Every professional understands this compromises the breathing,'' Dr Zakon said yesterday
However, he was criticised by other another radiologist for not explicitly listing the danger present to Mr Clarke's airways.
Chris Bartlett, counsel for Mr Clarke's wife, Nicole Clarke, asked Dr Zakon if he anticipated the patient would remain in hospital for observation based on the scan. ``Yes, I agree with you,'' he said.
He said Mr Clarke did not have aspiration pneumonia at the LGH.
The LGH's Dr David Mutasa said because of Mr Clarke's neck surgery he deferred to orthopaedic consultants, who were apparently happy for the patient to go home.
Dr Mutasa said he did not ``have the foot to put down'' in preventing Mr Clarke from being discharged.
The inquest before coroner Rod Chandler continues.