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”.
“We’ve got to live with that trauma,” said his wife Victoria.
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.”
Mr Hurst, a builder from Godmanchester, had a history of abdominal pain and was born with a rare undetected congenital diaphragmatic hernia.
The youth football coach had been experiencing mild symptoms for about eight months before bad abdominal pain led to his wife taking him to A&E, on 7 December 2018.
Mrs Hurst, who at the time was 25 weeks pregnant with their first child, said at hospital “he was just screaming out in pain”.
“It was horrific. I just started crying because I didn’t know what to do and no-one was listening to us – literally no-one,” she said.
Last month, an inquest into his death heard he spent several hours in A&E in “extreme pain” and a CT scan was delayed by 58 minutes because of a fire alarm.
Once completed, the scan showed a diaphragmatic hernia and fluid in his abdomen.
But while preparations were made for surgery he went into a cardiac arrest from which he did not recover and died in the early hours of 8 December.
The couple’s daughter, Alice-Rose Adam Hurst, was born in February
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”.
Mr Hurst’s sister-in-law, Margo Leftly, said: “Irrelevant of the outcome… it was more the way he was treated, communicated with and the fact that the pain management was incorrect.
“They left him in that amount of pain with no support for the last six or seven hours of his life.”
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The family have set up a charity in Adam’s name that aims to support those suffering from grief and said it would “carry on his legacy of helping people”.
Mrs Hurst said she also wanted to raise awareness of his condition because “if they knew he had one and he went into A&E that night he would have been rushed into surgery straight away”.
Dr Rege, from the hospital’s trust, said: “We would like to offer our condolences to the family of Mr Hurst during this difficult time.
“Following a thorough investigation we have implemented several changes and have now introduced a single trust-wide acute pain guideline and provided additional training to staff on pain management, communication skills and record keeping.”