A father from Devon was able to disconnect his oxygen and leave his bed before collapsing in a corridor. He was found dead by a porter at the Royal Devon and Exeter Hospital.
The coroner at the inquest into Calvin Marchant's death found "there were a number of errors, omissions and oversights that contributed to his death.”
The 48 year old was admitted with acute pancreatitis and died from cardio respiratory failure, vomiting, and pneumonia which developed in the days before his death.
The coroner ruled there was:
- an absence of a weekend management plan
- inadequate monitoring
- failure to allocate him a correct consultant
- an absence of further clinical examination and review.
She also said that if Calvin had been examined in the last few hours of his life there would have been clear signs for sepsis.
His family say they knew something was seriously wrong.