A Broken Hill man was wrongly diagnosed with lung cancer and underwent major surgery after a tiny fragment of someone else's cancerous tissue contaminated his own sample, an inquest has been told.
Dennis Charles Jackson died in January 2019, having spent more than 60 days in intensive care in the months after undergoing an upper lobe lobectomy on his left lung at the Royal Adelaide Hospital.
About a month after the surgery he returned to hospital where a diagnosis of hospital-acquired pneumonia was made.
While he was eventually transferred to a ward and accepted for rehabilitation his respiratory failure continued to worsen leading to his death.
Opening an inquest on Tuesday, counsel assisting Emma Roper said a scan performed on Mr Jackson in June 2018 showed a nodule and a satellite growth in his left lung.
A biopsy was subsequently performed to determine if the growths were cancerous and further tests were also performed.
A specialist found that the chances of the nodules being cancerous were low but ordered more samples be taken and, on analysis, a technician reported locating a free-floating fragment of squamous cell carcinoma.
Ms Roper said following that report and a meeting involving a multi-disciplinary team at the RAH, a recommendation of surgery was made.
But she said after sections of Mr Jackson's lung were removed, specimens sent to SA Pathology found no evidence of malignancy.
"It is anticipated that Your Honour will hear evidence that a minute piece of tissue belonging to another patient had been transferred to Mr Jackson's biopsy specimen during the embedding procedure at the Royal Adelaide Hospital laboratory," Ms Roper said.
The hospital subsequently apologised to the 67-year-old and his family while the error was later confirmed by DNA testing.
Mr Jackson returned to hospital about a month after the surgery when the diagnosis of pneumonia was made. He spent 63 days in intensive care and then further time on a ward before his death.
Ms Roper said the inquest would explore a number of issues including how the contamination of Mr Jackson's biopsy could occur, whether the piece of tissue should have been recognised as a contaminant and whether further investigations should have been conducted ahead of surgery.
It will also examine how Mr Jackson's left vocal cord came to be damaged.
The inquest was continuing.