Angry and exhausted, Andrew Knox broke down as he left the South Australian Coroners Court this week.
Anthony Schapel, the deputy state coroner, had just heard the final submissions in an inquest investigating the deaths of four patients underdosed during their chemotherapy treatment at two Adelaide hospitals.
Mr Knox was also underdosed, but has survived.
"We've been through hell and back," he told reporters.
"Not only physically, in my case, but the families have just been through these dragged out proceedings where we've found things that we ought to have been told in February of 2015."
For victims and families, this week marked the end of nearly two years of evidence on how such a mistake could happen, why it went uncorrected and who was to blame.
But their wait for answers is not over yet.
On a date to be set, Mr Schapel will deliver his findings on the deaths of Christopher McRae, 67, Johanna Pinxteren, 76, Bronte Higham, 68, and Carol Bairnsfather, 70.
It's been more than three years since it was discovered that they and six others battling leukaemia had received half doses of chemotherapy between July 2014 and January 2015.
The patients, being treated at the Royal Adelaide Hospital and the Flinders Medical Centre, were given one dose of the drug Cytarabine a day, when they should have been given two.
The mistake was traced to an oversight by Associate Professor Ian Lewis, clinical director of haematology, who signed off on an incorrect new protocol.
It was picked up more than six months later by a RAH pharmacist who queried a script, but the response to the mistake was slow - so much so that Mr Knox was given the incorrect dose even after it came to light.
The inquest examined the behaviour of doctors following the discovery, in particular the way they dealt affected patients the news their treatment had been compromised.
The husband of Johanna Pinxteren gave evidence that she was never told about the error, and he did not learn she was among the underdosed patients until after her death.
Another patient was told she was dosed once each day deliberately because, the inquest heard, her doctor was worried that telling the truth would be detrimental to her mental state.
Mrs Pinxteren died in June, 2015 - the first of the patients to succumb to the disease - and the bungle was made public that August.
An inquiry was then ordered, which found guidelines were not followed, supervision was inadequate and clinical staff failed to report and log the incident.
In February, 2016, eight clinicians were referred to the professional standards board, AHPRA, over the issue.
That June, the government offered $100,000 in compensation to victims or their families after Mr Higham fronted a parliamentary committee just weeks prior to his death.
The inquest was also opened, but it was February of 2017 before the first hearings were held.
Professor John Gibson, head of the Institute of Haematology at Prince Alfred Hospital, gave evidence that while the impact of the error on individual patients was difficult to measure, giving them a single daily dose was not "optimal".
He said patient outcomes may have been compromised, but would not comment on whether those who died would have lived longer if given the correct doses.
Two doctors were stood down by AHPRA in May 2017 over their role in the scandal, while another - Flinders Medical Centre consulting haematologist Dr Ashanka Beligaswatte - was cautioned for unsatisfactory professional conduct.
Key players Dr Lewis and Dr Agnes Yong were called to give evidence late last year.
Dr Lewis, who was told of the error on his return from holidays, acknowledged the mistake was "truly devastating" for families but said he "froze" and could not explain why he did not take immediate action.
Dr Yong, the doctor queried by the pharmacist about the error, said she was waiting for her superiors to respond.
The inquest was often slow and complicated by legal argument, but in May, after nearly two years of evidence, things looked to be wrapping up - but another blow was in store for the victims and their families.
On the day closing submissions were due to be heard, counsel for the doctors argued the coroner did not have the jurisdiction to make any findings because the deaths of Mr McRae and Mrs Pinxteren were not reportable under the Coroners Act.
Mr Schapel eventually ruled the deaths were reportable, but for Mr Knox, the legal challenge was another example of the lack of accountability he says he's seen from the very beginning.
"I believe it was an ill-conceived application in the first place taken by a group of doctors who put themselves before their patients," he said.
"It put the families and the victims through an enormous amount of unnecessary trauma again and I think that's quite heartless."
Mr Knox, who has sat through much of the inquest, said Mr Schapel had heard "some very shocking things", but would be reluctant to speculate on the coroner's findings.
Counsel assisting the court and counsel for the victims want the coroner to hand down findings against the six doctors involved in the dosing errors.
"I would like him to go further than what's been asked of him," Mr Knox said.
"I think there are more things that he would recommend than has been asked for."
