Medical regulators should investigate the plastic surgery industry after the death of a woman who fell ill during a breast-enhancement operation, a veteran coroner said yesterday. Delivering his final verdict before stepping down, Coroner Michael Chan Pik-kiu ruled the 2010 death of Zoey Leung Kwan, 24, to be a case of misadventure. But he said it raised questions that should be considered by bodies that regulate doctors. Chan suggested professional bodies, including the Medical Council and the Academy of Medicine, investigate and set down guidelines on what surgeries should be carried out only by specialist plastic surgeons and which operations should take place in hospitals, rather than clinics. The Medical Council said it would consider the coroner's recommendations. The inquest had been on hold since 2011, but resumed on Wednesday after the Department of Justice decided not to charge Dr Wong Kar-mau, who performed the operation. Before the adjournment, the court had heard that Leung went to Wong's private clinic on Nathan Road for the operation on April 30, 2010. Wong was a specialist in obstetrics and gynaecology, but had started performing plastic surgery in 1993. After being given anaesthetic, Leung had breathing problems and her limbs started twitching. But a surgeon working in the same building, who helped revive Leung, would not allow an ambulance crew to take her to hospital as they lacked a mask needed to help her breathe. The equipment arrived 45 minutes later and Leung was taken to Queen Elizabeth Hospital in Yau Ma Tei, where she died on May 11, after 11 days in a coma. Yesterday, Chan said the court could not rule on whether the amount of anaesthetic used on Leung fell within reasonable limits or not, as medical experts had given different opinions.