Cherie Guest may still be alive today if an eye surgeon had not operated on her while she was struggling to breathe.
As she lay on the operating table, the 61-year-old begged the surgeon to stop halfway through her cataract procedure, but he continued.
Her breathing deteriorated and she died after being taken to a public hospital in an ambulance.
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A Victorian coroner on Thursday found Guest's death was preventable and would not have occurred if specialists had cancelled her surgery.
Guest visited Melbourne ophthalmologist Joseph San Laureano's for a diabetic eye check, in July 2018, after being referred by her GP.
He said she needed surgery to remove a cataract and insert a stent to reduce eye pressure.
But Guest, who had several pre-existing health conditions, told the surgeon was could not lie flat due to breathing issues.
She also relied on a home oxygen tank to breathe and used a wheelchair.
San Laureano decided he would perform a two-part operation using a laser machine for the first stage, instead of conventional cataract surgery.
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After the consultation, Guest and her daughter Angela were concerned and called the Victoria Parade Surgery Centre (VPSC) to request a trial run before the procedure.
However, the trial was not conducted by San Laureano, it was done by his employee.
When he was told the trial was successful he made no further inquiries about how it went or whether it was adequate.
On August 18, San Laureano failed to properly assess Guest's fitness and went ahead with the two-part surgery.
After the first part of the procedure ended, he continued with the second stage despite Guest asking for him to stop and her lips turning blue.
A nurse who tended to Guest told the inquest she was "alarmed" the surgery went ahead despite her high risk and severe breathing issues.
Other medical professionals were surprised San Laureano didn't notice she was unfit for the operation and one said he was "astounded" that the surgery proceeded.
Experts called to give evidence told the inquest into the death, even if she was assessed as being fit for the surgery, it should never have been performed at VPSC.
She should have only been operated on at a hospital with close links to critical and emergency care, they said.
San Laureano and an anaesthetist had breached their professional obligation to Guest in continuing with the surgery, Coroner Katherine Lorenz said.
"By failing to recognise medical risks to Guest… San Laureano's care fell well below the standard expected of him as a surgeon," she said.
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