Mohammed Ismael "Bolly" Zaman, 31, died when he was being treated at Royal Shrewsbury Hospital.
Pharmacy dispenser Bolly, who had suffered a number of health problems due to being a Type 1 diabetic, died after an unidentified nurse pressed the "reset" button on his dialysis machine when the alarm went off, without checking the tubes were connected. He lost three pints of blood in seven minutes, went into cardiac arrest and died on October 18, 2019.
Bolly's family are suing the hospital for the part staff played in his death.
Kay Kelly, of Lanyon Bowdler Solicitors, who are representing the family, said: “The circumstances of this death are tragic for Bolly’s family and must also have been devastating for the nurses and hospital staff caring for him, particularly when they discovered that national guidelines for patient safety had not been implemented on the ward.
“They had not received adequate training which were likely to have made a difference and prevented this death.”
More from the inquest:
Evidence was given at Bolly's inquest at Shirehall last week, and Shropshire coroner John Ellery is expected to deliver his closing remarks and conclusion later this week.
Bolly's inquest heard that a dialysis assistant provided him with blankets to keep him warm in a cold room at the hospital. National guidance says that tubes should remain exposed so medics can monitor what is going on safely.
The inquest also heard that a national alert was issued after three near miss events involving tubes being covered. The information was not disseminated among colleagues on the unit.
Dr Johann Nicholas, consultant nephrologist for Shrewsbury and Telford Hospitals Trust, accepted there had been "systemic failings" regarding the training of staff.
Bolly's sister Arafina told of the "horrific" experience of seeing Bolly in his hospital bed covered in blood after he died. Paying tribute, she said: “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.
"He was a very religious person and often acted as a peacemaker in our family. His death has devastated us all.”
Bolly's dad was so shaken by his death he has not been able to return to work more than a year on.