Mohammed Ismael Zaman, known as Bolly, died after hospital staff failed to check the connection on his dialysis machine, despite it sounding an alarm after the catheter had become disconnected.
During Mr Zaman’s treatment at the Royal Shrewsbury Hospital on October 18, 2019, his dialysis machine set off a venous pressure alarm.
An unidentified member of staff reset the alarm without checking that the connection was still secure.
As a result of the reset, Mr Zaman bled out for seven minutes losing 49 per cent of his blood circulating volume.
He was found unconscious in a pool of blood and despite resuscitation attempts, died two hours later.
The coroner, Mr John Ellery concluded that the death was due to systems failure and individual neglect on the part of the unidentified staff member.
He said that he was satisfied that lessons had been learned by the trust.
On behalf of the family, Mr Zaman’s father, Shabier Zaman, said: “We are absolutely devastated about the tragic circumstances surrounding Bolly’s death, which could and should have been avoided.
“Bolly was improving with regular dialysis and was in the process of being considered for a possible kidney and pancreas transplant. He had a lot of hope for the future and had started making plans for a foreign holiday.
“To hear during the inquest that guidance and procedures for patient safety during dialysis were not followed has been heartbreaking. This tragedy should not have happened.
“Our priority as a family was to discover the circumstances in which Bolly died when he was supposed to be in the good care of the hospital. The investigations revealed considerable failings in care.
“We were relieved that the trust has learned lessons and urgently made changes to ensure that no other family has to go through this experience.”
Mr Zaman was 31 and was training to be a pharmacist.
However, from April 2019 he developed serious complications from diabetes type 1 and required kidney dialysis three times per week at the Royal Shrewsbury Hospital.
Following his death, investigations revealed that national guidelines for patient safety had not been implemented in the dialysis unit and that staff had not been trained adequately on the new guidelines, nor how to respond to all the alarms on the dialysis machine.
Following the inquest Hayley Flavell, director of nursing at The Shrewsbury and Telford Hospital NHS Trust (SaTH) said: “I wish to offer my sincerest condolences to Mr Zaman’s family for the loss of their much loved family member.
"My heartfelt sympathies go out to them. Following Mr Zaman’s death, we launched an investigation to examine and assess the care that he received.
"The investigation identified that he did not receive the high standard of care we wish to deliver, and I apologise unreservedly to his family for this.
“We have completed detailed action plans and a number of changes have been made to significantly strengthen and improve our standard operating procedures on the renal unit with robust re-training to ensure that all changes have been embedded.
“We have worked with Mr Zaman’s family and their solicitors and have agreed a settlement.
"However, I recognise that no amount of money will ever be enough to truly compensate Mr Zaman’s family for their terrible loss.
“We have been in contact with Mr Zaman’s family in the months since his death and have been working closely with the coroner’s office to prepare for the inquest.
“We will continue to support them as much as possible during this distressing time.”