The McLeods said hospital clinicians failed to appreciate early enough that the portacath inserted into 66-year-old Mr McLeod's superior vena cava vein in his chest the year before to administer chemotherapy had migrated into his trachea, causing rapid deterioration in his health and hastened his death.
Mr McLeod was under the care of Tauranga Hospital until his admission to Waipuna Hospice.
Dr Murray Hunt, clinical director at Waipuna Hospice, told the court he believed the portacath may have eroded into the trachea and called for an inquest because he believed the possible cause of death was medical misadventure.
Mr McLeod died in Waipuna Hospice on October 1, 2012, after suffering numerous cancers for eight years. Coroner Dr Wallace Bain was told the primary cause of his death was acute pneumonia and a chest infection.
Mrs McLeod said that on September 15, 2012, Mr McLeod brought up blood. When he attended Tauranga Hospital accident and emergency department the next morning, a chest X-ray confirmed the tip of the portacath was sitting in the wrong vein. Despite that, on September 19 the green light was given for him to have chemotherapy.
DHB consultant radiologist Dr Adam El Dieb said while he was not involved in Mr McLeod's care he was charged with reviewing his radiology X-ray images. He acknowledged the portacath misplacement should have raised a red flag but he and his colleagues had never encountered catheter migration into the azygos vein before.
Mrs McLeod said it was her husband's dying wish that his family push for changes to hospital procedures to prevent the risk of a similar tragedy.
The inquest continues today.