A Wodonga man who suffered a racing heart rate after a double knee replacement was the third patient to die from the procedure under the same surgeon, a NSW inquest has heard. 

Kenneth Toll, 62, died from a pulmonary thromboembolism in an Albury Wodonga Private Hospital ward on July 20, 2019, three days after orthopaedic surgeon Elie Khoury peformed bilateral knee replacement surgery on him.

Dr Khoury has been working at the private hospital currently operated by Ramsay Health Care for 25 years.

The Coroners Court of NSW, sitting in Albury, heard he had performed 94 bilateral knee replacements during that time, and three of those patients — including Mr Toll — had died.

The court heard Dr Khoury performed more than 300 arthroplasty procedures a year and his overall patient mortality rate post-surgery was below the generally accepted one in 1,000 percentage.

His work has since been the subject of an internal review.

Patient deemed high clot risk

The inquest into the medical care of Mr Toll heard he had an extensive list of health issues, including coronary artery disease, but that Dr Khoury did not ask him about his heart problems or consult with his cardiologist before the surgery.

Mr Toll's cardiologist, Naylin Bissessor, had deemed him  in "really good" cardiac health five months before the surgery, but his cardiology notes were not on the hospital's file.

Mr Toll had been flagged prior to surgery as a high embolism risk due to his age and obesity, and the court heard that risk increased with a double knee procedure and the use of tourniquets.

He had also been told by anaesthetist Graham Libreri to stop taking aspirin, which helps thin the blood, before surgery.

"It's a calculated decision," Dr Libreri said.

Racing heart failed to trigger referral

Mr Toll experienced three episodes of supraventricular tachycardia (SVT), or very fast heart rate, nausea and vomiting in the days following surgery.

He was discharged from the high dependency unit (HDU) onto a ward, where cardiac monitoring was reduced.

He was not referred to a cardiologist for review following the SVT episodes and reports of rib pain, despite the court hearing that Dr Khoury had intentions to do that.

Cardiologist Jan Albert Du Plooy said he was working at Albury Wodonga Private Hospital on July 19 when an HDU nurse showed him Mr Toll's electrocardiogram (ECG) as a training exercise, and he was not worried.

He did not access the patient's medical records.

"The ECG did not show any concerning features at that stage," Dr Du Plooy said.

He said he had no contact from Dr Khoury or Dr Libreri, and HDU staff expressed no concerns to him.

Barrister Lorna McFee pressed Dr Khoury on whether best practice would have been a referral to cardiologist, and he agreed.

Dr Khoury said he did not feel it necessary to follow up further with Dr Du Plooy, feeling "reassured" he had reviewed the ECG.

"There was no indication of a heart attack," he said.

Dr Khoury also told the court he believed the patient's need for 4 litres of oxygen, lower oxygen saturation levels, and lower hemoglobin did not indicate the development of clots, and he did not show symptoms consistent with fat embolism syndrome.

'It can be a sign'

Expert witness and cardiologist Mark Adams told the inquest the recurrence of the SVT should have triggered cardiology referral.

"A recurrence of it might suggest there might be some underlying cause for it, and in Mr Toll's case there was no medical history of him having suffered SVT … in the past," Dr Adams said.

Mr Toll also experienced limited mobility post-surgery due to being in the HDU, the court heard.

"Would that have increased his risk of venous thromboembolism?" Barrister Jennifer Hillier, who is representing the Toll family, asked.

"Potentially," Dr Khoury replied.

A 'harrowing experience'

In a statement read to the court by family friend Craig Rose on Friday, Mr Toll's family said his unexpected death had left a huge hole in their lives that would never be filled.

Family members described the army veteran as the "kindest, sweetest, [most] loving, generous, modest and sincere person that God ever put breath into".

The inquest heard family members were left distressed by seeing Mr Toll deceased in the hospital bathroom from what they thought was a routine surgery, and that each had suffered "some level of mental illness" since his death.

"The day Ken passed is so vivid in our memory. It haunts us every day," Mr Rose said.

The inquest heard life would be forever changed for Mr Toll's wife of 40 years, Wendy, and that he was missed at major family events, including his son Mark's wedding and daughter Lisa's 40th birthday.

"We wanted Ken's death to be the subject of an inquiry to make sure that processes are considered, changed, and improved to prevent future deaths and the pains and distress that comes with losing a loved one," Mr Rose said.

The family acknowledged there had been several changes made at Albury Wodonga Private Hospital since Mr Toll's passing.

"It is comforting for the family to know that we have been listened to, and hopefully, although we don't get to have Ken with us, other families don't endure what we've had to endure," Mr Rose said.

The inquest continues.