It's been revealed that a patient admitted to Flinders Medical Centre in Adelaide with severe neck pain died after being given an overdose of painkillers by staff.
In shocking evidence, the coroner has heard that the administration of the patient's medication was "seemingly disastrous."
Stephen Atkins' grief-stricken family have needed answers to the 53-year-old's death.
"He was the most beautiful son a mother and father could ever have, and the best friend I've ever had," his father Robert Atkins said.
Atkins was given high doses of the potentially lethal opioids Oxycodone and Fentanyl.
The inquest found that the drugs were administered too close together and were not "appropriately monitored."
"He went into hospital for some tests and we expected him to come out," wife Lee-Anne Atkins said.
The coroner was told pain management at Flinders was out of sync with the Royal Adelaide Hospital and the Queen Elizabeth Hospital.
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Given the drugs he was administered, it was found that Mr Atkins should have been transferred to a high-dependency unit.
"We'll wait for the outcome of the coronial investigation, see what recommendations are made, and make sure we can respond in a way that makes sure mistakes like this don't occur in the future," SA Health Minister Peter Malinauskas said.