Former Bega doctor Graeme Reeves breached his duty of care but is not guilty of the manslaughter of a mother who died days after giving birth in 1996, a judge has ruled.
Reeves, who became known as the "Butcher of Bega" after he surgically removed a patient's labia and clitoris without her consent, has been on trial in the NSW District Court over the death of 38-year-old Kerry Ann McAllister.
The judge-alone trial heard allegations Reeves ignored nurses' concerns about Ms McAllister's worsening condition and that he misdiagnosed her bacterial infection as a virus before she died from septicaemia.
Judge Peter Zahra on Friday found the 66-year-old not guilty of manslaughter, saying that while his treatment failures substantially caused Ms McAllister's death, they did not amount to gross criminal negligence warranting criminal punishment.
Ms McAllister died on May 14, 1996, five days after giving birth at The Hills Private Hospital at Baulkham Hills.
In delivering his judgment, Judge Zahra said Reeves breached his duty of care to Ms McAllister and his failure to consider the possibility of a bacterial infection, undertake appropriate testing and administer antibiotics amounted to negligence.
However, he couldn't be satisfied beyond reasonable doubt that Reeves misdiagnosed Ms McAllister when she first started running a fever on May 9, as it was unclear when the bacterial infection started and it was possible it co- existed with a viral illness.
The trial heard evidence her condition was elusive and rare, and diagnosing it was "one of the most difficult things to do", the judge said.
But while Reeves' initial diagnosis might have been reasonable, the judge found he should have reconsidered it by May 12 when Ms McAllister remained in significant pain.
Addressing allegations the doctor ignored nurses' concerns and refused to examine Ms McAllister, the judge noted Reeves' evidence at a 2013 coronial inquest that he saw her each day.
He said Reeves didn't fail to assess her symptoms as they arose, and didn't recklessly dismiss her symptoms or deteriorating condition.
Reeves didn't give evidence at his trial but he told the earlier inquest into Ms McAllister's death: "There's no grey area in this. It's simple. I made an error which cost her her life".
"I can't live with it, I can't live - I can't change it. It has happened," he said.
The deregistered doctor, who hugged his lawyers and walked from the court alone after the verdict was delivered, was jailed in 2011 for mutilating a woman's genitals while he was an obstetrician and gynaecologist at Bega and Pambula district hospitals between 2001 and 2003.
He was released on parole from Long Bay jail in 2013 after successfully appealing against an 18-month increase to his sentence.