The case of a man 76-year-old man who was discharged from the Launceston General Hospital two years ago, only to die at home the next day, has been scrutinised on the ABC's flagship investigative program Four Corners.
Monday night's episode, entitled 'Health Hazard', focused on potentially avoidable deaths and errors in Australia's rural and remote hospitals and put Tasmania's ailing health system in the national spotlight.
Statistics from the Australian Institute of Health and Welfare show the rate of potentially avoidable deaths spikes significantly the further away from a capital city you get.
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The episode begins in Launceston, and covers stories from other hospitals across the country, including Gippsland in Victoria and Broken Hill and Bega in New South Wales.
The subject of the Launceston segment is the late John Novaski, a Turners Beach man who presented to the LGH ED on October 9, 2017, after having experienced shortness of breath. Mr Novaski had previously had two heart attacks.
His GP, Tony Lyall, took an electrocardiogram and found there was a blockage in Mr Novaski's heart.
"His heart wasn't pumping as it should do normally," Dr Lyall said. "His condition was increasingly at risk with time."
Dr Lyall immediately wrote Mr Novaski a referral for the LGH, including with the letter a copy of the ECG.
At the ED, Mr Novaski was triaged as a category 3 patient, meaning he was to be seen within 30 minutes.
He was assessed in the waiting room by a fifth-year medical student, due to all other suitable spaces being occupied.
Tasmanian Coroner Rod Chandler's findings into Mr Novaski's death concluded that the medical student obtained Mr Novaski's medical history and carried out an examination. A chest x-ray was also ordered and blood samples were taken.
Mr Novaski's wife, Ann, said they'd expected him to be seen by a cardiologist at the hospital.
"And that didn't happen," she said.
A discussion with the ED registrar later led to Mr Novaski being discharged in the view that he was clinically well and had a review of his condition scheduled with a cardiologist within the coming days.
Dr Lyall said "it can't really be forgiven" that Mr Novaski was sent home in the condition he was in.
The next day, Ms Novaski returned home after running an errand and found her husband dead on the lounge room floor.
"It's just heartbreaking to think that perhaps if they'd have kept him at the hospital, I might have been able to hold his hand," an emotional Ms Novaski told the cameras.
Mr Chandler found Mr Novaski's care at the LGH "fell well short of the standard required".
"Most critical in my view was the decision to discharge Mr. Novaski without first ensuring that he was reviewed by a cardiologist ... a serious and 'hard to believe' misjudgment," his findings read.
Tasmanian Auditor-General Rod Whitehead also appears in the program, saying that over a period of five years, the number of adverse events in the state's hospitals had increased by about 60 per cent - and by about 50 per cent at the LGH, specifically.
State Health Minister Sarah Courtney declined the ABC's request for an interview but said in a statement that the government would be building extra space at the LGH so that it could open more beds as soon as possible.