An internal investigation into the 2021 incident identified multiple system failures, and recommended four reforms to improve safety.

In a statement to the Central Western Daily, a spokesperson for the local health district said: "All recommendations have been implemented."

As first reported by the Sydney Morning Herald, in January last year 66-year-old Carmel Haynes suffered cardiac arrest after a CT-guided biopsy needle burst a blood vessel in her lung.

No autopsy was conducted, and the NSW coroner reportedly chose not to investigate; attributing the death to "natural causes."

However, an internal health district review cited by Nine newspapers found: "Breakdown in communication [was] a contributing factor in the patient's death as the CT-guided lung biopsy was not necessary."

Mrs Haynes had been diagnosed with lung cancer following an ultrasound biopsy two weeks earlier, and a second biopsy was reportedly not required "to guide further treatment."

The clinician who scheduled the second procedure was unaware of the first, according to the report - and may have been suffering "cognitive fatigue" while covering for a colleague.

A screen monitoring Mrs Haynes' vital signs was allegedly obscured at the time of her death, and understaffing was reported by clinicians to be an ongoing problem at the medical imaging department.

Neither of these factors were found to have contributed to Mrs Haynes' death, and the recommended two clinicians were present during Mrs Haynes' procedure.

A statement from the Western NSW Local Health District spokesperson said, in part:

"[We] are subject to stringent requirements to review and act when serious, unexpected patient outcomes are experienced.

"WNSWLHD has an absolute commitment to clinical safety, which includes conducting Serious Adverse Event Reviews and referral to the NSW coroner where appropriate.

"Mrs Haynes' death was referred to the Coroner at the time of the incident. The Coroner's decisions whether or not to investigate further are made entirely independently.

"A thorough clinical review ... resulted in four recommendations being made for improvements. All recommendations have been implemented.

"The recommendations primarily related to improving communication between healthcare providers. The review found staffing was not a contributing factor in Mrs Haynes' death.

"Staff from WNSWLHD apologised to Mrs Haynes' family and provided opportunities to meet on multiple occasions during and following the course of the review."

Mrs Haynes' family was approached by The Central Western Daily for comment on the hospital's response, but declined.

A spate of potentially-preventable deaths in the regional health system have been investigated by the Sydney Morning Herald in recent weeks.

These include a woman who died in 2019 from a torn oesophagus in Dubbo Hospital, and a man who went into cardiac arrest at Cobar Hospital after high potassium levels were allegedly not adequately addressed.

A parliamentary inquiry sparked by the Nine paper's reporting has recommended a new ombudsman be formed, with the power to independently investigate deaths that may have been preventable.

To read more stories, download the Central Western Daily news app in the Apple Store or Google Play.

Send a letter to the editor using the form below ...