A coroner has urged the medical profession to ditch "antiquated technology" after linking a misdirected fax to the death of a Victorian cancer patient.
Hodgkin's lymphoma patient, 58-year-old Mettaloka Halwala, died alone in a hotel room near Shepparton in November 2015 from chemotherapy complications.
Days earlier a scan at a Melbourne hospital showed signs of potentially-fatal lung toxicity linked to Mr Halwala's treatment.
But the scan results were faxed to the wrong number.
Combined with other communication failures, it meant neither Mr Halwala nor his hematologist - who ordered the scan - were made aware before further treatment was administered at the Goulburn Valley Hospital.
On Thursday Coroner Rosemary Carlin found Mr Halwala had been "let down by the medical profession".
"I cannot be certain that Mr Halwala would have survived even with optimal treatment but he may have," she said.
"The shortfalls in his medical management deprived him not only of his chance of survival but also of the opportunity to have a more comfortable death surrounded by loved ones."
After Mr Halwala's last round of chemotherapy and the day before he was found dead, the father-of-two felt unwell and hematologist Robin Filshie suggested he go to hospital, but didn't make it.
The doctor only read the scan results after hearing from the unwell Mr Halwala, who was found dead before Dr Filshie took further action.
While "no one acknowledged responsibility for the communication failure," Coroner Carlin found there had been inadequate medical management by both Dr Filshie and the physician responsible for sending the report, associate professor Sze Ting Lee.
The coroner added it was "difficult to understand why such an antiquated and unreliable means of communication (faxes) exist at all in the medical profession".
She urged the faxing of imaging results to be phased out at Melbourne's Austin Hospital and for the development of national standards around the communication of results.
Mr Halwala's family welcomed the coroner's findings and said they had long questioned why the scan was ordered but the results were not followed up.
"In their view, their beloved husband and father should never have died in the way he did, alone and without medical treatment," a lawyer representing the family said in a statement.
Australian Associated Press