But a fax with the results of his scan was sent to the wrong number, Coroner Rosemary Carlin found. “It is difficult to understand why such an antiquated and unreliable means of communication persists at all in the medical profession,” Ms Carlin said in her inquest findings. This, combined with other "shortfalls in his medical management", meant neither Mr Halwala nor his haematologist Dr Robin Filshie at St Vincent's Hospital Melbourne was made aware of the results before a further fatal dose of same drug associated with the lung toxicity was administered. While no one acknowledged responsibility for the communication failure, Ms Carlin found there had been "inadequate medical management" at the hands of both Dr Filshie and the physician responsible for sending the report, Associate Professor Sze Ting Lee. "I cannot be certain that Mr Halwala would have survived even with optimal treatment but he may have," she wrote.

"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." In the months leading up to his death, Mr Halwala, affectionaly known as Mal, was living in a hotel in Tatura, a small town in the Goulburn Valley, due to his work as a civil engineer, while his family lived back in New Zealand. His wife of 27 years, Chula Halwala, said the family was still struggling to come to terms with his death. "Our hearts have been broken by this," she said. The last photo taken with Mettaloka Halwala and his wife Chula and daughter Dulanjali at dinner on November 14, 2015.

The weekend before he died, Ms Halwala and his two daughters visited him in Melbourne, but he was so severely sick with a chest infection that he struggled to breathe and walk. He told his wife he felt as if his whole body was on fire, especially his throat and ears, even though he was extremely cold. "I got the shock of my life when I saw him for the last time," Ms Halwala said. "But he never wanted us to worry about him. In everything he did, his family was at the forefront. It was so hard having him working away from us but all he ever wanted was for his two daughters to have a better life than we did. He dropped us off at the airport and drove back for work. It was the last time we saw him." Hours before he died, Mr Halwala called his wife to tell her he was feeling tired and she told him to call his doctor or go to the hospital. Mr Halwala called Dr Filshie who told him to go to the hospital, but he never made it there.

"He never wanted to make a fuss so he said he would just go to bed and that he would call me in the morning," Ms Halwala said. Ms Halwala said she hoped no other family would have to go through what they have. "We just want the medical industry to take full responsibility for a person's health and to make sure they are looked after and that results are always followed up, because if they are not then this is the outcome," she said. "But nothing will bring him back to us." In her findings, Ms Carlin called for the development of national standards around the communication of results. "These standards should be as explicit as possible in setting out the roles and responsibilities of diagnostician and referring doctor," Ms Carlin said.

She also called for the Austin Hospital to phase out fax transmission of imaging results as a matter of urgency. "It is difficult to understand why such an antiquated and unreliable means of communication exists at all in the medical profession," Ms Carlin said. A lawyer representing the family, Gabrielle Feery, from Maurice Blackburn, said in a statement that the family agree with the coroner that all physicians – regardless of whether they are treating the patient face-to-face – owe a duty of care to the patient.