Apathy among doctors and nurses in two Queensland hospitals led to the deaths of three patients, an inquest has found.
Graham Gulliver and Joanne Harrison died at Mossman Hospital in early 2012, and Aileen Moreton at Atherton hospital, also in 2012.
All three died from infections.
Their deaths were the focus of an inquest in the Cairns Coroners Court in November.
In her findings, released this week, Coroner Jane Bentley was highly critical of the care the three patients received.
Ms Bentley said none of the trio received appropriate care and that more timely and appropriate diagnoses and treatment could have prevented their deaths.
She found staffing levels at the two hospitals were inadequate and that there was a reluctance among staff to utilise on-call doctors.
Ms Bentley said the "culture of apathy" was widespread and required urgent change.
"Further, there was a culture of failure to adhere to policies and procedures, failure to correctly document medical notes and a failure to consider the patients' medical records and history contained in the patients chart," she said.
She recommended Mossman Hospital employ a full time radiographer and that the region receive funding for a nurse educator.
Ms Bentley also ordered the regional health service implement a new workforce model and report annually to her office on its development.
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