Andres Martinez was 24 when he died in March 2010.
Judge Michael Dinkel writes in a fatality inquiry report that the surgeon used the wrong instrument during the operation.
The bladed instrument pierced one of the large arteries supplying blood to the pelvis and legs.
Blood from the puncture didn't clot properly.
Dinkel says the surgeon should have waited for the proper surgical instrument before proceeding.
The judge points out Alberta Health Services has made a number of changes and listened to the victim's father on ways to provide support and better communicate with grieving families.
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