The same fatal mistakes are made again and again in hospitals because recommendations made after one death are not followed across the state, former NSW deputy coroner Carl Milovanovich says.
Twenty months have passed since an inquiry into NSW hospitals and Mr Milovanovich still has concerns about patient treatment.
"The one thing that I have constantly encountered as a coroner was the repetition of the same mistakes," Mr Milovanovich said about evidence presented at coronial inquests into hospital deaths.
He was delivering a paper to the Australian Lawyers Alliance Medical Law Conference in Sydney on Friday.
"There is no doubt that systemic problems will exist in an organisation as large and as diverse as the New South Wales health system."
Mr Milovanovich presided over the Vanessa Anderson inquest.
In 2005, the 16-year-old was taken to Royal North Shore hospital after being hit on the head by a golf ball and died two days later.
He found that she died of "systemic failures" at the hospital and the inappropriate administration of pain relief.
The inquest sparked the Garling inquiry, which concluded in late 2008 and resulted in 139 recommendations into acute care in NSW public hospitals.
Mr Milovanovich said on Friday that coroners now take great steps to deliver their findings into preventable hospital deaths to the highest level in state government.
"The area health services are all separate little administrative units and they don't talk to each other and that's one of the problems," he said.
"And there's no guarantee that a recommendation that might have resulted from a death at Wagga will be implemented in an area health service at Lismore."
He acknowledged the findings of the Garling report and said an individual practitioner's mistakes reflected a larger issue.
"We do have dedicated and caring professionals working in the health system and their failings are invariably associated with the lackof resources, equipment and experienced staff and overriding budgetary constraints," Mr Milovanovich said.
"Almost every medical or hospital death that I've examined would fall into one of these categories."
During the question and answer session, he agreed there was still a lack of holistic patient care in the public hospital system.
"That the parameters end according to the carer's level of expertise or professionalism and they don't take that extra step of communicating to the next level," Mr Milovanovich said.
"That seems to be an emerging problem and that's what the Garling Report identified."
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