Family tell inquest of concerns after Timothy Cowen's post-op death
The brother of a disabled man who died after a routine operation has told an inquest his death should never have happened.
Timothy Cowen, 51, died after a gall bladder operation at Wrexham Maelor Hospital in May last year.
The inquest in Mold was told there was a lack of communication about his care.
The coroner, recording a narrative verdict, said lessons had undoubtedly been learned, but he was still concerned about training.
John Gittins said there should be mandatory training for all staff working with patients with learning difficulties.
Mr Cowen's brother Philip had told the inquest earlier that the hearing was "not about blame, but about finding out what happened".
"This should have been a never-event. Procedures should have been put in place and followed," he said.
'No observations taken'
Philip Cowen said his brother, who had severe learning difficulties and had to be fed via a tube through his stomach, was "a bubbly and happy person".
He told the coroner, John Gittins, that on the day Mr Cowen from Caergwrle, Flintshire, was due be discharged no observations had been taken all day.
Earlier, Mr Cowen's mother, Berenice, told the inquest staff had tried to feed him through the tube while he was lying down on two occasions.
However, his notes stipulated he should only be fed sitting up because of the risk of reflux and pneumonia.
Fleming Ward sister Janet Edwards told the hearing staff were used to caring for patients who were tube-fed into their stomachs and she was "confident" staff were aware they needed to be at a 45 degree angle and would never feed patients lying flat.
She said carers who had visited Mr Cowen may have been concerned he was being fed in bed when they would usually feed him sitting in a chair.
"We were still feeding him in the correct position," she said.
Responding to the fact that Mr Cowen's observations were taken at 08:00 BST on the day of his discharge, she said that should not have happened and observations should have been noted more regularly.
But she said that since his death, improvements had been made with spot audits held.
Nesta York, who was the project manager of Y Maes, the care home where Mr Cowen lived, told the inquest she had concerns about his feeding on a visit to the hospital the day after his operation.
After the hearing, Betsi Cadwaladr health board apologised for "the range of clinical and service errors which occurred during Mr Cowen's stay at the Wrexham Maelor Hospital in 2013".
Angela Hopkins, executive director of nursing and midwifery, added: "A detailed investigation was undertaken with the involvement of the family and a comprehensive action plan and range of recommendations developed.
"These included ongoing training for staff to ensure that standards are met and maintained and this is being closely monitored."