A surgeon yesterday admitted it was common practice not to read nurses notes before operating.
The admission came during the Birmingham inquest into the death of well-known businessman and rugby stalwart Harry Jeavons-Fellows from a blood clot earlier this year.
Mr Jeavons-Fellows, aged 39, was operated on for a compression to his Achilles heel tendon in August and died three weeks later.
Nursing notes that accompanied him to the operating theatre flagged up on the front cover that he had been treated for a blood clot, or pulmonary embolism, in 1997.
Dr Dr Keith Porter, who carried out the operation, admitted had he known Mr Jeavons-Fellows' medical history he might not have died.
Richard Follis, representing Mr Jeavons-Fellows family, asked Dr Porter if he read the nurses notes before operating.
He replied: "I didn't read the notes. Since this tragic death I have canvassed many of my colleagues and none of them routinely read nurses' notes."
Mr Follis later asked: "If something is written in huge letters with a couple of asterisks on the front of the file can you tell us whose attention it was thought to catch?"
Dr Porter replied: "Not mine because I don't read nurses' notes."
Mr Jeavons-Fellows was a corporate financier at Aberdeen Murray Johnstone Private Equity. The father-of-three, who played rugby for Stourbridge, met Dr Porter before his operation but did not tell him about his previous condition.
After the operation, he was advised to take three weeks off work but is believed to have returned within days.
Asked by Mr Follis if more robust steps had been taken in the knowledge of his previous medical history Mr JeavonsFellows would have died, Dr Porter replied: "One would have hoped that he wouldn't have died. I couldn't guarantee that would have happened."
In his summing up, Birmingham coroner Mr Adrian Cotter said: "I am satisfied the nurses knew in 2005 that he had had previous pulmonary embolism and they thought the treatment given was sufficient."
On Dr Porter's belief that Mr Jeavon-Fellows may not have died if more robust steps had been taken, he said: "In my view that is all you can draw from that. There is no guarantee at all that if Mr Porter had the fullest possible information and the operation had gone ahead with the fullest possible precision that this sad event wouldn't have occurred."
In a narrative verdict, the coroner recorded cause of death as a "massive bilateral pulmonary thrombosis".