Former Wollongong neurosurgeon Dr Maurice Jerome Day appeared in Port Kembla Court today for a coroner's inquest, after the death of his patient following a surgery in 2018.
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Dapto woman Elizabeth Davies, 62, died in the hours after her lumbar spine surgery, conducted by Dr Day at Wollongong Private Hospital.
The advocate assisting the coroner Sergeant Tina Xanthos said Ms Davies's death was "in every sense of the word, a tragedy".
Coroner Roger Clisdell heard that on 19 June 2018, Dr Day used the Mazor Renaissance Spine Robotic system to help place screws into Ms Davies's lower back.
The technology uses images from patient scans to create a model of the spine. Using the model, doctors can plan the trajectory, width and length of screw implants.
In court on Thursday, Dr Day said that on the day, the CT scanner in the operating room was not usable. He added that they had to combine images taken that day with images taken from a CT scan the night before.
"I believe what happened in her case was a Paralax error," Dr Day said in court.
"When an x-ray image is taken, and an x-ray passes through the body, the angle at which the x-ray passes through the body can be varied through the layers of tissue it has to pass through.
"Those images, when they were matched to the CT scan, created an image that looked accurate but in reality was shifted a little bit to the right."
During Ms Davies's surgery, when Dr Day first tried to turn the screw in the bone, it "didn't feel right", he said in court. He took it out, re-did the planning and made a slight change of trajectory, the court heard.
While Dr Lauren Green, who was assisting in the surgery, was putting in the second screw, the doctors were alerted that Ms Davies was going into hypotension and her blood pressure was dropping rapidly.
Dr Day called vascular surgeon Dr Tam Nguyen, who jogged to the hospital from his consultation rooms on Crown Street.
Dr Nguyen found a tear in the inferior vena cava, the largest vein in the human body, showing significant abdominal bleed.
"I knew the survival rate is very very very low for an inferior vena cava injury," Dr Nguyen said in court on Thursday.
"I've never encountered anything bigger."
"I've trained in some of the major trauma centres in Australia, and I've never come across this type of situation," he said.
The Mazor Renaissance had been used for 700 procedures in Australia. This was the first reported death when the robot was used.
An investigation by the Therapeutic Goods Administration said it was unlikely that a device failure contributed to the death of Ms Davies.
The Coroner's Inquest will continue on Friday.
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