Patient's heartbreaking final words before death
These were the last words spoken to a father by a young woman who died within hours of complications arising from elective weight loss surgery.
Brooke Tiddy was admitted to St George Private Hospital in Sydney on September 19, 2018 for bariatric surgery recommended by her doctor, who assessed her as "super super obese".
But her hopes for a new lease on life were dashed when the 32-year-old died two days later.
An inquest into her death seeks to assess the effectiveness of the hospital's processes and prevent similar deaths.
On Monday, her parents and two sisters remembered the mental health support worker as "an energetic and enthusiastic soul who would do anything for anyone".
Ms Tiddy had been "deeply motivated to improve her health" and was "nervous but excited" when she embarked on the journey "she would never have a chance to complete".
Her family said the passionate baker's life was cut tragically short by a failure to investigate her underlying health issues before her surgery.
"This oversight cost Brooke her life and shattered her family's and friends' trust in the health system," they said in a statement.
"We hope (this inquest) will lead to measures that ensure such preventable tragedies never happen again".
The inquest was told Ms Tiddy lived with an "extremely rare" condition known as sponastrime dysplasia, which affects the muscles and skeletal system.
Her surgeon Dr Vytauras Kuzinkovas said he hadn't previously heard of the condition and didn't do any research about it until after Ms Tiddy's death.
One of the associated features is a narrowing of the airways which was ultimately found to be Ms Tiddy's cause of death, the inquest was told.
An autopsy found her airways had severely narrowed to the approximate diameter of a drinking straw, which almost certainly occurred before the surgery.
Dr Kuzinkovas said Ms Tiddy downplayed her asthma and depression and didn't reveal she had croup or narrow airways during an initial consultation.
An in-depth assessment of her medical history would have likely revealed such risk factors, he said, but he hadn't thought it was needed at the time.
With the benefit of hindsight, Dr Kuzinkovas accepted Ms Tiddy was a high-risk patient whom he would have referred to specialists before surgery.
Intensive care unit staff looking after Ms Tiddy were not informed about her sponastrime dysplasia and its significance, the inquest was told.
If he had been aware of the link between her condition and narrowed airways, ICU doctor Michael O'Leary said he would have called in a specialist.
"This has been the worst experience I've had in my career. I felt very alone that night," he said.
"The only thing looking back on it I would do differently would be to get someone else to give me a hand."
Dr O'Leary said he wasn't sure whether a pre-operative assessment would have prevented MsTiddy's death because what they really needed was to access her full medical history.
"In a sense we were set up to fail in this case because there was all of this information that was kept from us," he said.
The inquest continues on Tuesday.
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