A father of three who was given too much morphine in a Brisbane hospital died after staff missed opportunities to diagnose his deteriorating condition, a coroner has found.
Michael Calder, 33, died at the Holy Spirit Northside Private Hospital at Chermside on July 11, 2014 after being treated for viral meningitis and repeatedly complaining of severe headaches.
The real estate agent had been in hospital for three days when he died of opiate toxicity, with a morphine level in his blood in the potentially lethal range.
Deputy State Coroner John Lock delivered the findings of the inquest into his death on Friday, two days before he would have been celebrating another Father's Day with his young sons.
Mr Lock found there were missed opportunities to diagnose Mr Calder's deteriorating condition.
He said the communication between treating doctor Rodd Brockett and nursing staff was "lacking" and there was no evidence the parties had discussed a treatment plan for Mr Calder.
He found there were times nurses did not record Mr Calder's pain scores, report pain or oxygen saturation levels and what they did in response.
One nurse, who was later dismissed, did not record providing oxygen or taking any other action when Mr Calder's oxygen levels were at 90 per cent, which constitutes clinical deterioration.
Mr Calder did not complete a patient history form when he was admitted so Dr Brockett was initially unaware he had a history of obstructive sleep apnoea, which may have contributed to his deterioration.
Dr Brockett had acknowledged his medication regimen was wrong and had provided an emotional apology to the Calder family for his practice and treatment, Mr Lock noted.
The coroner did not refer the doctor or treating nurses for disciplinary action, however, they still may be referred by the Health Ombudsman.
Mr Lock said the hospital had already made improvements, which two expert doctors agreed were comprehensive, and did not make any further recommendations for the facility to implement.
Outside court, Mr Calder's partner Andrea Young said she hoped lessons would be learned from his death so no other family would have to go through the same ordeal.
"To be a 33-year-old man with a headache and to be administered a drug overdose in a hospital by health professionals is unthinkable," she said. "But it happened.
"We hope his legacy will be a safer medical system for all Australians. He will be forever loved and missed."
The family's lawyer, Sarah Atkinson, said while the hospital had made significant changes the coroner felt were good enough, his death should never have occurred.
"There were a number of missed opportunities that shouldn't have happened and Michael should be here spending Father's Day with his family," she said.
