A rural health service and a doctor have offered their condolences to the family of an Indigenous man who died after a blood clot likely linked to Q fever went undiagnosed.
Paul Harris died at Hay Hospital, in regional NSW, on October 17, 2019, after being treated for a suspected case of community-acquired pneumonia.
But an inquest has been told the 43-year-old meat worker also had Q fever and a blood clot in the lungs, which went undetected at the small rural hospital.
Q fever is a disease caused by bacteria, generally spread to humans from livestock.
Ahmed Hosni, one of two doctors who worked across the GP clinic and the hospital in Hay, recalled Mr Harris being admitted in late September 2019 for a "straight forward" case of community-acquired pneumonia.
Mr Harris responded to antibiotics and was soon discharged from hospital.
But on October 9, he returned to the clinic saying he'd coughed up blood and Dr Hosni re-admitted him.
Dr Hosni considered the possibility of a pulmonary embolism during a consultation at the clinic that day, but further examinations at the hospital led him to believe recurrent pneumonia was more likely than a clot.
"I changed my mind," Dr Hosni told the inquest at Griffith Local Court on Tuesday.
He said he did not test for Q fever because the antibiotics used to treat pneumonia would manage both conditions.
Five days later, Mr Harris's health was not improving and Dr Hosni ordered more blood tests, X-rays and a CT scan, but did not transfer him to the larger hospital at Griffith.
Expert reports provided to the inquest said the case should have been escalated and the two doctors at Hay Hospital acted on "most likely" scenarios, rather than ruling out life-threatening conditions like clots.
But Dr Hosni said pulmonary embolisms do not have specific diagnostic features.
"This is the difficulty and this is why it scares every single medical practitioner," he said.
Unlike a tertiary hospital, the rural facility did not have access to advanced screening services such as a specialised test that can detect lung clots.
He and the other doctor shared duties across the clinic and hospital, often on-call after hours and on weekends.
Now in a different role in Victoria, Dr Hosni said he often thought of Mr Harris's death and went through a period of "over-investigating" patients as a result.
He had since learned that Q fever can spark an immune response that increases the risk of clots.
"I feel very sorry for what's happened," Dr Hosni said to Mr Harris's family as they sat in the courtroom.
"I didn't know Paul for a long time, but he was very easy to talk to and he was a very beautiful person."
Barrister Richard Sergi, representing the local health district, also offered "sincere and profound" condolences.
"The Murrumbidgee Local Health District acknowledges without any reservation the immeasurable loss that is Paul's death," Mr Sergi said.
NSW Health had improved conditions to reduce rural doctor fatigue in recent years, introduced a program that allowed patients' families to elevate their concerns and expanded cultural training programs.
The inquest continues before Deputy State Coroner Rebecca Hosking.
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