LAUNCESTON General Hospital clinical services director Dr Peter Renshaw said a combination of failures saw a patient discharged hours before he died.
Yesterday was the final day of evidence at the inquest into the death of Donald John Clarke, 40, who died at his Deloraine home on July 24, 2011, from apparent breathing difficulties.
Mr Clarke, who had neck surgery 10 days earlier, presented at the LGH with significant swelling in his neck and a closing airway on July 23, 2011.
However, he was given the all- clear and sent home from the emergency department after undergoing CT scans and being seen by an orthopaedic registrar.
The next morning he was dead.
Counsel for Mr Clarke's wife asked Dr Renshaw if he believed there was a systematic failure on the day.
"I believe there were a combination of failures, it's not only systems," he said.
Dr Renshaw said this included individual error and communication breakdown between the doctors at the hospital.
"And then a premature discharge," lawyer Chris Bartlett said.
"Yes," Dr Renshaw said.
The inquest was adjourned for parties to make submissions and coroner Rod Chandler to deliver his findings.