A Tasmanian palliative care patient was accidentally given a fatal dose of painkillers, 10 times greater than the amount prescribed.
Cancer sufferer Brian John Kelly, 71, was taken by his wife to the state's North West Regional Hospital on January 3 last year after his condition worsened at home.
He died the following day, with a coronial investigation revealing he had been given 20 milligrams of the painkiller hydromorphone.
Mr Kelly had been prescribed two milligrams of the drug.
"While I am quite satisfied that the administration of 10 times the appropriate amount of hydromorphone was not deliberate, it bespeaks a shocking lack of attention to basic principles," Coroner Simon Cooper wrote in findings published on Friday.
The consequences were immediately fatal with the care falling "well short" of an acceptable standard, Mr Cooper said.
Mr Kelly, who was receiving palliative care at home, had been diagnosed with prostate cancer in early 2000 and with bowel cancer in 2012.
In February 2019, he was diagnosed with lung cancer deemed too extensive for surgery.
A medical certificate recorded lung cancer as the cause of Mr Kelly's death, with the coroner's office notified of an "issue" with the documentation on January 13 after a regular review process.
Mr Cooper commented that the obligation of reporting deaths in line with the Coroners Act 1995 is one cast upon medical practitioners.
"On no reasonable view of the circumstances was it appropriate to issue a medical certificate of death," he wrote.
"Mr Kelly's death should have been reported to the coroner at the time it occurred."
Mr Cooper said immediate steps need to be taken at Burnie's North West Regional Hospital to ensure a similar accident doesn't happen again.
Recommendations in a Tasmanian Health Service report, which was not contained in the coronial findings, should significantly address the issue, he added.
The Service has been asked to comment.