The quality of care provided to two elderly patients who were separately treated by the same doctor in Perth before they died is being examined at a coronial inquest.
Anna Maria Winter, 94, had a cancerous growth affecting her vulva that was causing her pain when she was referred to specialist urologist Daryl Stephens at Waikiki Private Hospital in April 2014.
She had an indwelling catheter inserted and a biopsy indicated a carcinoma in situ, counsel assisting the coroner Toby Bishop said on Monday.
Due to an irritation, the catheter was later replaced with a suprapubic catheter and Dr Stephens also conferred with a plastic surgeon, who agreed the lesion would require a resection.
The next day, Ms Winter was transferred to St John of God Hospital by taxi, which Mr Bishop said was contrary to the Waikiki Private Hospital ward policy and procedure manual that states transfers must be by ambulance.
Upon arrival, Ms Winter became ill, collapsed and required resuscitation.
She received palliative care for her illness and died on May 20, 2014.
A post mortem found the cause of death was sepsis complicating management of vulval carcinoma in an elderly woman with severe coronary artery atherosclerosis.
Deputy state coroner Evelyn Vicker is examining whether the insertion of the suprapubic catheter had any connection with the sepsis.
Separately, in April that same year, 72-year-old John Houghton complained of pain in his left flank and a test confirmed he had a urinary tract infection.
An ultrasound also showed a bladder wall irregularity, which prompted his GP to refer Mr Houghton to Dr Stephens with a radiology report that stated the possibility of a neoplastic mass lesion could not be ruled out and a further cystoscopic evaluation was suggested.
Dr Stephens replied to the GP that he could not feel any masses and Mr Houghton's bladder was not palpable.
"His main problem is at present having sterile urine for his up and coming hip operation," Dr Stephens wrote.
Mr Bishop said the nature of Dr Stephens' examination would need to be examined in the inquest, adding a cystoscopy did not appear to have been performed.
Dr Stephens referred Mr Houghton to the Peel Health Campus for a second transurethral resection of the prostate and noted a flexible cystocopy would be required beforehand.
Mr Houghton had a right hip replacement in June, but 10 days later went to Peel Health Campus emergency department.
A CT scan showed invasive bladder cancer and Mr Houghton was transferred to Fremantle Hospital but his condition deteriorated and he received palliative care until his death from the illness on July 11, 2014.
Ms Vicker is investigating whether Dr Stephens' examination of Mr Houghton's bladder for cancer was adequate.