A HARD-HITTING report into the death of a 91-year-old patient at Huddersfield Royal Infirmary says his medical assessment was inadequate.
And it said lessons must be learned from the death of former soldier Harry McNulty, who was admitted to the Infirmary with breathing difficulties last December.
Within hours, he had apparently fallen out of bed, become unconscious and broken an arm and a hip. He died six hours later.
His family accepted his death was due to natural causes but they were devastated when they discovered he had the wrong name tag on his wrist after he had passed away.
The tag belonged to someone who had died previously and was still in the hospital mortuary. Both families had to re-identify their loved ones.
An investigation was launched by the Calderdale and Huddersfield NHS Trust and Mr McNulty's grieving family have had to wait until now for a full explanation of what happened in the 12 hours he was in the Infirmary.
The inquiry report concluded that the nursing assessment was "inadequate" although the care given to Mr McNulty was acceptable.
His fall out of bed would have been prevented had side rails been in place.
And the inquiry team has called for a review of the nursing assessment documentation in the medical assessment unit, as well as a review of the role of the night sister.
Today Mr McNulty's son Robert welcomed the inquiry's findings.
"It has taken a long, long time but at last we have been told what happened," he said. "Nothing will take away the sadness of what happened to my father but at least I and the other relatives know what happened, what went wrong. They have said in the report that lessons will be learned so hopefully no more families will have to go through the anguish that we have had to suffer."
Mr McNulty also left two daughters and four grandchildren.
The former military policeman and retired plumber lived in Springwood. He was admitted to hospital on December 22 after one of his daughters, Mrs Elizabeth Fryer, found he was having difficulty breathing.
Relatives left him there at 7pm and he seemed fine but shortly after 10pm he had fallen out of bed and was unconscious. He had broken an elbow and had a suspected broken hip. He never came round and died at 4am.
In a report to the family, Dianne Whittingham, chief executive of the Calderdale and Huddersfield NHS Trust, apologised.
"May I first of all offer my formal apology on behalf of the Trust for the shortcomings which the investigation has identified in your father's care," she said.
"While sadly his death from medical causes could not be prevented, his final hours may have been more comfortable had it not been for the fall.
"Sadly we cannot change what has happened but we can learn from our mistakes."