The family of a father-to-be have criticised hospital staff who left him "screaming out in pain" in the final hours of his life.
Adam Hurst, 31, died from a rare type of hernia a few hours after arriving at Hinchingbrooke Hospital in Cambridgeshire, last December.
The hospital found Mr Hurst's pain management and the communication with him and his relatives was "inadequate".
The Medical Director of North West Anglia NHS Foundation Trust, Dr Kanchan Rege, said: "Our staff strive to provide high quality care at all times and this was not the case in this instance."
At the inquest into his death, the coroner concluded it was "not possible to say whether on the balance of probabilities earlier surgery would have resulted in a different outcome due to the rare and complex nature of the surgery". But the hospital's serious incident report, seen by the BBC, found Mr Hurst's pain "should have been more aggressively managed, from the outset".
It also found the frequency of his observations was "inadequate" and stated the documentation in the emergency department "was generally very poor from the nursing staff that cared for the patient".
The report also said "clear explanations to the patient and relatives are essential to allay fears and reduce anxiety".
Source: BBC News, 5 December 2019
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