The parents of a seven-year-old boy who died following heart surgery have been told Bank Holiday staff shortages at an NHS hospital were partly to blame.
Luke Jenkins, from St Mellons in Cardiff, died in hospital on Good Friday after suffering cardiac arrest.
Luke, who was born with a congenital heart defect, had undergone successful corrective heart surgery at Bristol Children's Hospital.
He was expected to make a full recovery, but he died within a week.
An investigation by University Hospitals Bristol NHS Foundation Trust classified the incident as 'catastrophic' and found a catalogue of avoidable errors contributed to Luke's death, along with clinical patient factors.
The report identified there to be 'low and unsafe nurse staffing' for a cardiac high dependency unit.
'Limited team-work and communication' and 'failure to recognise and monitor deterioration' were also highlighted in the report, which additionally found that staff were confused about who to call in the initial stages of the emergency.
One paragraph of the report reads: 'It was suggested that some members of the junior nursing and medical team were unaware of the fact that there was a chest opening pack on the resuscitation trolley... this lack of knowledge contributed to a delay in the opening of the chest'.
It went on to say the delay was 'minor' and 'would not have affected the outcome for the patient'.
But it did find that the team were 'not familiar' with how to use the piece of equipment because cardiac arrest was rare in the ward situation.
Luke's parents Stephen Jenkins, 30, and wife Faye, 27, say they're still fighting for answers.
Deborah Lee, the Acting Chief Executive for University Hospitals Bristol NHS Foundation Trust, has released a statement expressing sympathy for the family, and outlining some of the complexities in the case.
The report has now been passed on to the Bristol coroner, and an inquest is due to be held.