A personal beef between two doctors played a key role in the lack of specialist staffing at the Royal Adelaide Hospital at a time when two patients died from strokes, an inquest has found.
South Australian Coroner Mark Johns has also ruled that recruiting a third stroke specialist was abandoned for budgetary reasons, describing the move as "extraordinary".
And he said at the very least there was "consternation and confusion" among hospital staff on the morning the men died and "in some cases it verged on near panic".
The coroner investigated the deaths of 60-year-old Michael John Russell and 87-year-old Leslie Robert Graham at the RAH in April last year.
At the time the hospital's two neuro-interventional radiologists (INR), who perform a delicate procedure to remove blood clots in the brain, were both on leave.
Mr Graham was admitted after suffering a stroke at home while Mr Russell suffered a stroke after a failed procedure to clear a blocked artery.
In both cases, an INR specialist from the Flinders Medical Centre, Dr Steve Chryssidis, was hurriedly called in to perform the clot retrievals but the operations were unsuccessful.
In his findings on Thursday, Mr Johns singled out one of the RAH specialists, Dr Rebecca Scroop, for particular criticism.
He said it was the "personal antipathy" that existed between Dr Scroop and Dr Chryssidis and her negative view of his technical competence that resulted in him not being asked to fill in when both she and her fellow INR specialist, Dr James Taylor, were on leave.
The coroner said this was despite the fact Dr Chryssidis was trusted by authorities to provide the same service at another hospital.
Mr Johns described Dr Scroop as an evasive and unconvincing witness and said it would have been the "obvious solution" to have Dr Chryssidis provide the INR service at the RAH in her plan to cover the absence of herself and Dr Taylor.
"It is legitimate to ask why it was not enacted," the coroner said.
In relation to the stalled recruitment process, Mr Johns said he had no doubt a third specialist would have been in place at the time the two men died had it not been stopped.
But for all his criticism of the circumstances surrounding the two deaths, the coroner made no recommendations.