The death of a retired police officer whose head became trapped between the rails and mattress of his hospital bed was an "avoidable accident", a coroner has said.
Max Dingle, 83, died 15 minutes after he was found "entrapped" on a ward at the Royal Shrewsbury Hospital in May 2020.
Concluding an inquest into Surrey-born Mr Dingle’s death, a senior coroner found resuscitation had not been attempted despite the pensioner electing for life-saving intervention and having a pulse when he was found.
Earlier this month, Shrewsbury and Telford Hospital NHS Trust, which runs the hospital, was fined £1,333,334 for failing to provide safe care to Mr Dingle and another patient – whose case is not linked – who died in different circumstances.
Senior coroner John Ellery said Mr Dingle's medical history showed he had suffered with a heart condition, lymphoedema and sleep apnoea.
The coroner said that Mr Dingle, of Newtown, Powys, in mid-Wales, "remained in hospital until May 3, at 10am, when he was found with his head trapped between the rails and mattress of his hospital bed.
"He suffered a cardiac arrest – from which resuscitation was not attempted – and he died at 10.15am."
Nobody from the hospital trust was present in-person for the hearing but family members, including Mr Dingle’s son Phil, dialled in from Australia.
Mr Ellery said an initial post-mortem examination gave a cause of death of heart disease "and did not consider the entrapment caused or contributed to the death".
However, Mr Dingle’s son "did not accept" those findings, instead commissioning expert consultant forensic pathologist Johan Duflou, from the University of Sydney, to review the findings and post-mortem examination.
Prof Duflou gave a cause of death of “entrapment with positional asphyxiation”.
After comparing and discussing their findings, both pathologists then agreed “entrapment did play a significant part in the cause of death”, Mr Ellery said.
The criminal inquiry ended this month after the trust admitted failings in connection with the care of two patients, including Mr Dingle.
Concluding the inquest, Mr Ellery said: “Based on all the evidence, the conclusions of this inquest are Mr Dingle’s death was an avoidable accident.”
At Telford Magistrates’ Court earlier this month, a judge imposed an £800,000 fine on one of two charges relating to the death of dialysis patient Mohammed Ismael Zaman, 31.
He also fined the Shrewsbury trust £533,334 over a charge brought in relation to Mr Dingle’s death.
The trust, which was recently the subject of a highly critical report into maternity services it offered between 2000 and 2019, admitted the charges through its barrister.
Separately, an independent review of maternity services, chaired by Donna Ockenden and published in March, found “repeated errors in care” at the trust, which led to injury to either mothers or their babies.
Some 201 babies could have – or would have – survived had the trust provided better care, the report said.
Dr John Jones, Acting Medical Director at The Shrewsbury and Telford Hospital NHS Trust, said in a statement.
“On behalf of the Trust, I want to offer our sincere apologies and condolences to the family involved in this tragic incident following today’s outcome. The failures in the provision of care meant the patient and their family were badly let down by the Trust.
“A series of immediate actions were implemented by the Trust following internal investigations and an external review to ensure that all necessary steps were taken to address the failings.
“I want to re-emphasise how sorry we are for the grief that has been caused and stress our commitment to continue improving the quality of care we provide.”