STAFF on a Morriston Hospital ward were so busy they were "running around chasing their tails" on the day a man with learning difficulties died, an inquest has been told.
And the inquest into the death of Paul Ridd was also told that his carers, who had joined the 53-year-old's family at his bedside, were asked by busy staff if they were able to carry out tasks for which they had not been trained.
Giving video evidence to the hearing at Swansea Civic Centre was Dr Charles Turton, an advisor to the Parliamentary and Health Service Ombudsman which upheld a number of complaints made by Mr Ridd's family about his treatment.
Asked whether the shortcomings in treatment amounted to gross failings, he said: "There were a number of shortcomings.
"Individually I do not think any were gross.
"My difficulty is whether or not taking them on the whole amounts to gross failings.
"I would say it is very, very close to gross. If it was in my team, I would have been profoundly uncomfortable about the care he had received".
Mr Ridd, of Ynysmaerdy Road, Briton Ferry, was admitted to the hospital's intensive therapy unit (ITU) on New Year's Eve 2008 for an operation on his perforated bowel. He died on January 23 due to secretions on his lungs which caused respiratory problems.
Lyn Williams, a manager for former support organisation Prospects, told the inquest he had known Paul for five years having cared for him, and that he had learning difficulties, epilepsy, and was non-verbal in his communication.
Describing Paul as "a character", he said that leading up to his death he had repeatedly asked staff for an air mattress, and that he had not been toileted.
Mr Ridd's carers were asked to change a bag containing his waste, and he added: "Support staff would have been willing to do anything, as long as there had been training provided."
A portmortem report concluded that the cause of death had been due to respiratory failure, with retention of secretions.
The inquest was also told that Mr Ridd had undergone a tracheostomy, and that secretions from his throat needed to be removed with regular suctions, but questions arose over whether the instructions were passed on when he was transferred from the ITU after 19 days to another ward.
Dr David Hope, ITU consultant, told the hearing he had made the instructions for suctions every two to four hours, which would have been recorded in his medical documents, but they had not been picked up in the handover process when transferring him from ITU to Ward G, as his condition appeared to be improving.
But he added that strict procedures had been introduced into Abertawe Bro Morgannwg University Health Board hospitals since Mr Ridd's death in an attempt to prevent a recurrence.
In his evidence, Dr Turton first praised the treatment Mr Ridd had received in the weeks before his death.
He said: "It was good care. But for the timely resuscitation, he would not have survived as long.
"The care was good in the emergency department and surgery would have been an extremely challenging operation."
But he said there were shortcomings below basic standards of care expected, and highlighted a lack of involvement with an intensive care outreach team.
Coroner Philip Rogers, chairing the inquest, asked him whether he would have expected to find such a team in a hospital the size of Morriston at the time of Mr Ridd's death in 2009.
Dr Turton said: "Yes.
"They would have been present in large hospitals."
The Ombudsman's report highlighted failings in the transfer from ITU to Ward G, and that observations had not been taken with necessary frequency.
It noted that Mr Ridd's consultant had clearly asked for attention from physiotherapists and speech and language therapists, but "it was not recorded this had happened" and that inadequate actions had been taken on the basis of deteriorating observations.
Dr Turton added: "It is unfortunate that after so much excellent care over three weeks, things went wrong at the end."
The inquest continues today.