A MUCH-LOVED father and husband would still be alive today if he had received proper medical care, an inquest heard.

Nicholas Dietzold, 31, of Stainburn, Workington, died on August 4 last year at the Cumberland Infirmary, Carlisle.

At an inquest held in Cockermouth on Monday, Coroner Nicholas Shaw concluded that Mr Dietzold’s death was due to natural causes, contributed to by neglect.

The inquest heard the father of two had been out for an anniversary meal with his wife, Rachel. He had started feeling unwell the next day, the following day he went to Accident and Emergency at the West Cumberland Hospital in Whitehaven.

Mr Dietzold had been diagnosed with Crohn's Disease earlier in the year. Following an investigation, it was suggested there was an obstruction to his bowel and so he was transferred to the Cumberland Infirmary.

On arrival at the Carlisle hospital, there was a backlog of ambulances and a very busy Accident and Emergency Department. "His admission to hospital was massively delayed by miscommunications," said Dr Shaw. He consequently spent more than four hours in the ambulance.

Surgical registrar Dr Baldredin Mohammed was not called until two hours after his arrival in the ambulance, the inquest heard. He came down to arrange for painkillers.

"Once Nick was in the department Dr Mohammed made a treatment plan in the hope matters would settle down naturally as the alternative might be quite major surgery," said Dr Shaw.

"He left the treatment plan with staff in the emergency department but that's as far as it goes. There is no evidence it was acted upon."

Apart from the administration of some morphine, Mr Dietzold appears to have received no care between 2am and 7.45am, when he was found deceased in his cubicle when Dr Mohammed returned.

A post mortem revealed the medical cause of death was aspiration of gastric content, due to a small bowel obstruction due to Crohn's Disease.

"Young people are resilient and can stand a lot," said Dr Shaw. "But he wasn't getting enough fluids and was losing fluids by being sick or having diarrhoea. His kidney function was deteriorating."

With regard to the aspiration in his airways, Dr Shaw said: "I suspect this was pre-mortem and it's just become too much for Nick's body and he has slipped away sometime between 6.45am and 7.45am."

A Serious Incident Investigation and CQC inspection was carried out following his death.

Dr Rod Harpin, interim executive medical director of North Cumbria Integrated Care, apologised to Mr Dietzold's wife, Rachel, who was legally represented at the inquest

"I wish to ensure Rachel that lessons have been learned as a consequence of Nick's death," he said.

He outlined the changes that were being made. These include putting patients in wards rather than a busy emergency department and improving communications. The trust has also agreed to increase staff nursing numbers.

In his summing up, Dr Shaw said: "Had Nick been admitted directly to the surgical ward he would not have died and that's been acknowledged by the trust.

"Specialists would have monitored him closely. Action would have been taken that was not taken in the emergency department."

He said to the trust representatives: "You have outlined a number of changes which seem to me will be beneficial, particularly regarding transfers, beds, senior clinicians talking to each other, trying to stop people waiting in ambulances.

"I'm fully aware that A&E are under enormous pressure because they're getting a lot more work than they should be getting. GP surgeries are harder to access, people are frustrated and get fed up waiting for an appointment and so they come to A&E.

"All these things land at A&E's door and it's very very difficult to maintain the standards needed.

"I feel in this case the ball was completely dropped. People saw Nick walking around the department and thought he must be alright. They waited until the morning and of course it was too late."

He said: "I'm happy that changes have been made and this will be for the best.

"This should be a 'never' type event and it's been dealt with appropriately. We also have the reassurance of CQC monitoring follow-up as well."

He thanked Mrs Dietzold, who was legally represented. "I would like to thank Rachel for her part in this and would like to pass on my condolences. For a wife and two young kids to lose their dad is just appalling."