Sheffield hospital bosses have apologised as certain aspects of care fell 'fell short of standards' after a pensioner died through persistent nosebleeds.
Sheffield coroner Christopher Dorries has written to bosses at Sheffield Teaching Hospitals in relation to the death of 83-year-old Terrance Millington.
Mr Dorries' report said Mr Millington was admitted to Weston Park Hospital on November 12, 2015 with severe back pain related to metastatic cancer. He also suffered from 'significant pre-existing respiratory disease'.
Six days later, Mr Millington suffered a nose bleed which was initially dealt with. Unfortunately he then suffered a second bleed which was again dealt with but with 'more difficulty'. However a third bleed proved hard to control and the 83-year-old suffered a fatal heart attack.
"The persistent nosebleed was found to be the trigger for the physiological failure leading to death," Mr Dorries said.
An investigation by hospital bosses said the on-call doctor 'slept through the ring tone of her mobile phone' despite repeated calls.
The coroner said in a 'Prevent Future Deaths' report he 'raised concerns' the on-call senior doctor 'did not make satisfactory arrangements' to ensure that she would waken if telephoned.
He added further concerns the next on-call consultant lived 50 minutes away in Retford and 'would have had no opportunity to attend promptly'.
However, the report acknowledged even if a consultant of the particular experience was inside the hospital, they may not have reached Mr Millington due to rapid deterioration.
The inquest also noted that whilst one of the two specialist nasal packs requested by a junior doctor arrived from the Royal Hallamshire site, the other one was wrong and couldn't be used.
In a letter sent to Sheffield hospital bosses, Mr Dorries said: "During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken.
"It is acknowledged that an incident investigation was undertaken by the Trust at my invitation during the inquest which sets out steps to be taken to prevent a repetition of the contact issue.
"Nonetheless I believe this report remains necessary so that lessons might be learnt beyond the Sheffield Teaching Hospitals Trust."
Dr David Throssell, medical director at Sheffield Teaching Hospitals NHS Foundation Trust said: "Our deepest condolences go to Mr Millington’s family and we are very sorry that some aspects of our care fell short of the standards we would normally expect.
"We have taken this very seriously and have reviewed where we can make changes to limit the chances of these circumstances happening again, in particular reinforcing the need for on-call staff to always respond to requests for assistance in a timely way.”