A South Australian coroner says it is a "truly dreadful thing" that four cancer patients underdosed on chemotherapy could have spent their last days wondering if their lives had been cut short.
But Deputy Coroner Anthony Schapel ruled on Friday he could not say with any certainty whether that was the case.
Mr Schapel handed down his findings on the deaths of leukaemia patients Christopher McRae, 67, Bronte Higham, 68, Carol Bairnsfather, 70, and Johanna Pinxteren, 76.
The four were underdosed at the Royal Adelaide Hospital or the Flinders Medical Centre between July 2014 and January 2015.
Mr Schapel said the issue should have been dealt with through a royal commission, which could have also examined the cases of six other patients who were also underdosed but are still living.
Mr Schapel found the four patients who died and a survivor, Andrew Knox, received treatment that was less effective because it was administered once a day instead of twice daily.
But he said it was not possible to say whether the survival period of any of the patients was significantly shortened.
"It is, in my view, impossible to say one way or the other," he said.
Mr Schapel found that the bungle could have been avoided if the hospitals involved had adopted the "eviQ chemotherapy protocol system", already in place at the Queen Elizabeth Hospital.
He recommended to the state's health minister, Stephen Wade, that a statewide chemotherapy protocol system be developed for the treatment of haematological illnesses.
"To my mind there is a clear need for uniformity as between the chemotherapy prescription systems across the board in South Australia," he said.
He said a statewide committee should be established to govern protocol development and alteration, after the inquest heard the errors were made following a change in dosing protocol.
Following the publication of Mr Schapel's findings, Mr Knox said the coroner's conclusions were in line with expectations.
"I guess none of us really expected that there would have been a finding that the underdosing caused us to die and relapse," he said.
"The big thing for my family, and I think other families as well, is the recommendations that will come out of it, just to try and ensure that other families don't have to go through the same thing."
