Mohammed Ismael 'Bolly' Zaman, 31, lost nearly half of his circulating blood after his dialysis machine became disconnected while he was having treatment on October 18, 2019.
His inquest at Shirehall heard yesterday that an unidentified nurse pressed the “reset” button on his machine after the alarm went off, without checking that his tubes were still connected. For the next seven minutes he then lost 250ml of blood a minute – 49 per cent of his blood.
Medics tried to save him but it was too late.
Bolly’s sister Arafina told how she and her cousin were “horrified” when they went in to find him lying in a pool of his own blood.
The family is suing the hospital over his death.
Bolly, who worked at Severn Pharmacy in Shrewsbury, was a Type 1 diabetic and had suffered a foot ulcer early in 2019, which later led to complications. He was in and out of hospital over the following months and had two cardiac arrests – one in June and another in August.
The court heard that he was having dialysis at the Royal Shrewsbury Hospital three times a week, and the family said they understood that he was put in a side room for his dialysis due to testing positive for a bacterial infection.
The inquest heard that Bolly, who was 5ft 2ins, naturally suffered from the cold, and that the room he had his treatment in was chilly. He wore a tracksuit and used extra blankets while undergoing treatment, blocking his tubes from view. His room was also out of view of the nurses' station.
In the agreed facts read out by coroner John Ellery, it was accepted by the hospital that national guidance was not followed in relation to having catheter access points showing.
A statement was read to the court from Arafina, who said of Bolly: “We were extremely close. He was like a father figure to me, even though he was younger. We did everything together, including shopping and holidays. It was a huge shock when he became unwell.”
She said she received a call from a nurse at the hospital just after 3.10pm on the day he died.
“She said he had suffered a cardiac arrest and I needed to get to the hospital immediately”.
Arafina joined her family in a room, where a doctor told them what had happened. She then went with her cousin Kabir to see Bolly’s body.
“It was a horrific sight,” she said. “Blood was all over the bed and there were two nurses cleaning up.”
She added: “He was a very religious person and often acted as a peacemaker in our family. His death has devastated us all.”
Another family statement from Shabier, Bolly’s dad, was also read to the court.
He told how Bolly was looking forward to Kabir’s wedding, and was hoping to look smart on the day in a Prince of Wales suit, pearl cuff links and a new watch.
“I attended every dialysis session with him except for the week he passed away, as I had undergone an operation,” said Shabier.
“I received a call on October 18 saying he had died and I should go to the hospital. The doctor said there would be an investigation into what happened. I wasn’t in the right frame of mind to ask questions.
“I’ve not returned to work since it happened. I don’t feel ready to face anyone.”
Dr Johann Nicholas, consultant nephrologist for Shrewsbury and Telford Hospitals Trust, accepted there had been “systemic failings” regarding the training of staff. The inquest continues.