Colleen Stefanyszyn, of the Newcastle suburb Merewether, vomited faecal material for several days before her death following surgery at Newcastle Private Hospital in December, 2008.
It was "the worst red flag that a surgeon would see", a medical expert said during a NSW Supreme Court hearing that resulted in negligence findings against her gynaecologist and the hospital, and the possibility of contempt action against the hospital relating to the Supreme Court proceedings.
Mrs Stefanyszyn's death was preventable, NSW Supreme Court Justice Monika Schmidt found in a decision on Tuesday that was highly critical of the hospital and its breaches of duty of care that contributed to Mrs Stefanyszyn's death.
Justice Schmidt accepted Newcastle gynaecologist and obstetrician Dr Oliver Brown's admission that he breached his duty of care to Mrs Stefanyszyn and that it had resulted in her death.
Mrs Stefanyszyn's death "could have been prevented, had available surgical steps been taken", Justice Schmidt said.
Mrs Stefanyszyn, 61, had vaginal hysterectomy elective surgery at the hospital on December 1, 2008.
During the operation a loop of suture material "inadvertently looped around Mrs Stefanyszyn's bowel", resulting in a blockage, Justice Schmidt said.
She lived for just four days after the surgery, vomiting faecal matter from the third day, starting with a "coffee-coloured fluid" on the night of December 3.
While Dr Brown's response to Mrs Stefanyszyn's symptoms until the third day was reasonable, it was the medical experts' common ground that his approach to her subsequent care "was not only wrong, but inexplicable, given her deteriorating condition" that included continued faecal vomiting, Justice Schmidt found.
"Despite Mrs Stefanyszyn not recovering from the surgery as was expected and her deteriorating condition, the cause of her symptoms was not investigated, the blockage was not identified and surgical steps necessary to remove it were not taken, with her death the result," Justice Schmidt found.
"The result was that the blockage was not identified or addressed; infection set in; she repeatedly vomited faecal material; she inhaled some of that material with resulting pneumonia; her electrolytic balance became disordered; her oxygen levels deteriorated; and finally, she suffered a fatal cardiac arrest."
Justice Schmidt was highly critical of the hospital, its breaches of duty to Mrs Stefanyszyn which were "more extensive than it finally admitted", the failure of its staff to record observations of Mrs Stefanyszyn on the three days before her death, and the hospital's decision not to call evidence to address issues of its breaches.
Dr Brown's "failure to give evidence in support of his own case and the hospital's failure to call evidence in its, is that such evidence would not have assisted their respective cases", Justice Schmidt found.
The hospital's failures "did not give rise to a mere possibility of injury, but actually materially contributed to the death which resulted from both its failures and those of Dr Brown", Justice Schmidt found.
The matter returns to court on Friday where Justice Schmidt will consider whether the hospital should face contempt proceedings over aspects of the court case.
Justice Schmidt noted the hospital, Mrs Stefanyszyn's husband Walter and daughters Leigh and Megan had settled a compensation case.
In a notice in the Newcastle Herald on the second anniversary of his wife's death Mr Stefanyszyn wrote: "I have lost my soul's companion, a life linked with my own. Day by day I miss you more, as I walk through life alone. Forever Wal."
Her daughters wrote: "What is home without a mother? All things this world may send, but when we lost our darling mother, we lost our dearest friend. Love Leigh and Megan."