A Sydney surgeon forced multiple herniated organs from a patient's chest and delayed potentially life-saving surgery, according to damning inquest findings.
Cardiothoracic surgeon Dr Peter Flynn performed the botched operation to repair a diaphragmatic hernia from a procedure he had performed years earlier.
The inquest into Sean Thomas Montgomery's death found the 70-year-old died from multi organ failure and cardiac arrest days after what should have been a routine procedure on September 9, 2019.
Deputy State Coroner David O'Neil found Dr Flynn responsible for a series of failures including inattention to detail, insufficient review of medical documents, blunt force of multiple organs and an unacceptable delay in follow-up surgery.
"I formed the view that his approach to aspects of his work revealed a lack of attention to detail and an apparent desire to prioritise speed over precision and thoroughness," he said in recent findings.
Mr Montgomery was referred to the surgeon by his GP after experiencing shortness of breath.
CT scans revealed abdominal organs including his liver, colon and bowel had herniated through a defect in the diaphragm into his right chest.
However, the inquest found Dr Flynn "failed to recognise that organs had in fact herniated through the diaphragm" and did not properly review the CT imaging.
Despite the operation carrying "significant risk of morbidity and mortality", Dr Flynn also failed to inform Mr Montgomery of the risks.
While operating, Dr Flynn caused widespread damage to multiple organs.
Tears and defects on the bowel and liver were caused by instruments used to push the organs back into the chest.
Mr Montgomery's bowel "had been handled roughly and a significant amount of force had been used to push the bowel from the chest into the abdomen," Mr O'Neil said.
Evidence submitted to the inquest also found "blunt force injury to the liver, a hole in the liver so severe it had injured a bile duct and bile was leaking".
Mr Montgomery's condition deteriorated in the night following the operation.
But a failure to complete a thorough and accurate operation report kept other medical staff in the dark as to the seriousness of his condition.
"I find that Doctor Flynn's operation report did not accurately record the operation performed by him and had the potential to mislead readers as it tended to portray an uneventful procedure," Mr O'Neil said.
Mr Montgomery required two further surgeries but suffered a cardiac arrest and died on September 13 in Penrith's Nepean Hospital.
The inquest heard the delays in returning Mr Montgomery to surgery were unacceptable.
"Time was of the essence in relation to Mr Montgomery's prospects of recovery and the inexplicable delay was inexcusable," Mr O'Neil said.
The cause of death was severe metabolic acidosis due to multi organ failure leading to cardiac arrest.
"However, the cardiac arrest occurred in the context of the consequences of the first surgery," Mr O'Neil said.
A complaint for unsatisfactory professional conduct has been filed against Dr Flynn.
