An hour after being discharged from hospital following a collapse while out walking an Abergele man was asked to return because a junior doctor had realised that not all his details had been checked.

On his return to Glan Clwyd Hospital it was confirmed that John Rogers had suffered a heart attack and should have a pacemaker fitted.

An inquest in Ruthin heard, however, that it was further errors which led to the death of the 56-year-old just 10 days later.

When he returned to hospital on February 24, 2020, he was classified as “low risk” of suffering Deep Vein Thrombosis (DVT) - a blood clot in the leg – because he was due to have the operation within two or three days..

He was scheduled to have the pacemaker fitted on February 28 and so his blood-thinning medication was stopped to reduce the risk of complications.

However, the procedure was twice postponed before it was finally carried out on March 2 but the medication was not resumed in the meantime. That meant that he did not have anti-coagulant medication for eight days.

David Pojur, assistant coroner for North Wales East and Central, said that because of the delay a further risk assessment should have been carried out, especially as Mr Rogers also suffered from the co-morbidities of dementia and multiple scleroris.

“There was a change in circumstances because of his prolonged stay,” he said.

Mr Rogers, who worked at the Abergele Tesco store, was discharged after the operation but four days later his wife Deirdre took him back to accident and emergency because he had a pain in his leg, and he was found to have a blood clot.

While in hospital he suffered a heart attack and died on the 10th, and the cause of death was given as aspiration pneumonia due to prolonged cardiac arrest and pulmonary embolism, the clot having occurred in hospital.

Dr Gordon Black, a general physician specialising in stroke treatment, said: “The DVT occurred in hospital and could have been prevented, and subsequent issues including the cardiac arrest could also have been prevented.”

Dr Black disagreed with the findings of an internal review which found that the risk assessment was carried out properly did not increase, and told the inquest that other steps, such as the use of pressure socks, could have been taken.

Dr Mick Kwmwenda, leader of the panel which carried out the review, said Mr Rogers had apparently remained fairly mobile throughout, but Mrs Deirdre O’Byrne-Rogers, said her husband was “virtually confined to his bed and chair” the whole time.

In the review the Betsi Cadwaladr University Health Board accepted that Mr Rogers should not have been discharged when he was initially.

Recording a narrative conclusion, Mr Pojur said it was an “omission” not to carry out a second risk assessment and the review had not addressed the whole issues.

“Had he been given the appropriate anti-coagulants, on the balance of probabilities he would not have suffered and died at that time. There was an omission in his care and his death was preventable,” he said.

After the hearing Mrs O’Byrne-Rogers declined to comment.