Deputy state coroner Hugh Dillon handed down the report following last month's inquest into the death of Toni Ann Peadon, held in Sydney.

The 48-year-old wife and mother-of-four, known professionally as Dr Medcalf, died at Westmead Hospital on August 6, 2012 from complications that arose during an operation to replace defective internal defibrillator leads in her chest.

As a lead was removed, the report said, a major heart blood vessel tore, "causing her to bleed suddenly and so profusely that her life was unable to be saved despite emergency surgery".

Dr Medcalf had a defibrillator implanted after she was diagnosed with a heart condition years earlier following a move to work at Canberra Hospital.

Her husband Brian Peadon gave evidence a doctor performing the operation provided inaccurate information about the level of risk involved and "had they been told there was a risk of death, they would not have consented to the procedure". This was disputed by the doctor.

He and another doctor involved in the procedure admitted there had been failures on the part of their team to prepare properly for an emergency, the report said, with a cardiothoracic team not notified of the upcoming lead extraction nor were operating theatre staff warned to be on standby.

The report said both doctors had developed "significant expertise in the procedure" and had a "low rate of complications". The deputy state coroner also suggested in the report Dr Medcalf understood the procedure well and would most likely have sought to confirm the team was experienced, therefore it "seems more likely than not that Toni gave informed consent to the procedure".

Although a patient suffered a serious tear during a procedure two months before, there had been no deaths at Westmead Hospital due to laser lead extraction.

A consultant cardiothoracic surgeon called on to give expert opinion commented the only way to prevent the injury was "not to undertake the procedure".

He also suggested there was so little time available to save a patient from a catastrophe that the procedure "ought ideally be carried out in a hybrid operating theatre with a cardiothoracic team present in the room".

One of the doctors who performed the procedure told the inquest it had been performed in a cardiac catheter laboratory, or 'cath lab', because its imaging equipment was more powerful than that in general operating theatres, allowing for greater accuracy and therefore the patient would be safer.

While the injury was "almost certainly unsurvivable in the best of circumstances", the report said, the ideal environment for lead extractions was a hybrid operating theatre combining the facilities of a cardiac 'cath lab' with the facilities and staff of a cardiac operating theatre in case emergency open heart surgery was needed.

A hybrid theatre was not available at Westmead Hospital at the time of Dr Medcalf's surgery.

The coroner did not believe the injury could have been foreseen, with the report noting most of the evidence suggested the doctors took all reasonable care.

The coroner suggested Dr Medcalf was "appallingly unlucky that the lead had become embedded in her blood vessel wall".

Dr Medcalf's death had, however, prompted changes in lead extraction procedures at Westmead's cardiology department, the report said.

These included plans for a hybrid theatre, and, until that was built, for lead extractions to be carried out in a cardiac operating theatre with a cardiothoracic team on standby.

The report also recommended introducing specific consent for lead extraction procedures outlining alternatives, the risk of complications, what procedures were in place if emergencies arose and outlining the doctor's personal level of experience and outcomes performing the procedure.

The report said it was apparent Dr Medcalf had touched the lives of many people and those who loved her had honoured her with projects to carry on her work in a legacy that would benefit the community for years to come.

"It was also very evident during the inquest that the doctors who were involved in her fatal operation directly or indirectly were deeply upset by her death," the report read.

Dr Medcalf and her husband grew up and were educated in Dubbo. She specialised in emergency medicine, working in Dubbo for several years before taking up a role at Canberra Hospital.

While living in Dubbo, Dr Medcalf helped establish Macquarie Anglican Grammar School and was heavily involved in swimming in the city.

She was also an elite athlete who represented Australia in triathlon in the Masters Games.