Coroner's concern at patient's death at Ysbyty Gwynedd
The family of a man whose final days were dogged by communication problems at a hospital say they hope lessons will be learned.
Robert Stokes, 52, of Anglesey, who had Huntington's Disease, died from an abdominal abscess in February.
Deputy coroner Nicola Jones told the inquest in Caernarfon she was concerned by several lapses in communication at Ysbyty Gwynedd in Bangor.
Betsi Cadwaladr University Health Board said it would review the issues.
The inquest heard that instructions for food not to be administered via his feeding tube were missed by a dietician.
The coroner also expressed concern that a slightly smaller tube had been fitted while he was being cared for at a nursing home but the hospital had not been notified about this when he was admitted the next day.
The inquest also heard that hospital notes were inappropriate and, despite the consultant asking for a scan as a matter of urgency, it was delayed by more than 24 hours by other clinicians.
Mrs Jones, who recorded a narrative verdict, said communication was the big issue and it was unfortunate that this was not given special attention.
Mr Stokes was unable to communicate so it was especially important, she said.
After the hearing, a solicitor representing Mr Stokes' wife Susan said she wanted lessons to be learned from her husband's case.
Betsi Cadwaladr said in a statement after the inquest: "We would like to express our sincere condolences to the family of Mr Stokes.
"We will be reviewing the communications issues around this case and will ensure that where necessary, lessons are learned so that patient safety standards are improved."
Mr Stokes was a computer engineer but in recent years his condition had deteriorated with Huntington's Disease, a hereditary disorder of the central nervous system, and he was unable to leave his bed.
His consultant said he was very ill, disabled and prone to involuntary movement.