Nursing staff ignored pleas for a doctor to see a patient who was pale, clammy, perspiring and in excruciating pain, an Adelaide coroner has found.
Anthony Douglas Stock's death "would most likely have been prevented" had a doctor attended on him when the pleas were made, about six hours before he suffered a heart attack, the coroner found.
South Australian State Coroner Mark Frederick Johns called for an enquiry to establish the identity of the staff on duty and why the pleas were ignored.
"This case can only be explained by incompetence or, worse still, lack of care," he said on Thursday in his findings of the inquest into Mr Stock's death.
The 64-year-old was flown to Adelaide's Flinders Medical Centre after sustaining pelvic fractures after being thrown from a horse on his property at Meningie, on the state's Lower Lakes, on December 9, 2009.
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The coroner found he died on December 15, after suffering considerable internal bleeding on the afternoon of December 12 which led to a cardiac arrest late that night.
The coroner said the hospital notes, and lack of them, in relation to the December 12 ward round were unsatisfactory and "leads to a lack of accountability" for Mr Stock's treatment that day.
An opportunity was missed to discover that routine bloods had not been taken which meant haemoglobin levels could not be measured.
Mr Stock's wife, who saw him at 3.30pm, described him as being "extremely pale, perspiring profusely, felt clammy, his skin smelt acidic, his stomach was bloated, he was in extreme pain and was very agitated".
"I find that Mr Stock and Mrs Stock separately made requests of staff that a doctor be called but this did not happen," the coroner said.
Their daughter also asked a nurse at the nursing station to find out why her father's call bell for assistance had been unanswered.
In calling for an inquiry, Mr Johns said if the staff member is identified he or she should be required to explain why a doctor was not called.
"Unless staff are held accountable in such situations there is every likelihood that they will repeat poor practices and behaviours," he said.
