The individual errors and omissions that occurred in this case might happen at any of our own hospitals

Dr Ruth Brown

Part of the problem was that staff were over-stretched, struggling to cope with high patient demand with inadequate resources.

It says as a result staff came to accept "grossly inadequate outcomes as normal" and warns that the same mistakes could be repeated.

The report makes 15 recommendations designed to ensure that patients are prioritised according to their clinical need.

Mr Rogers, 74, died after he was left for nearly nine hours on a trolley at the Accident and Emergency Department of Whipps Cross University Hospital, in Leytonstone, east London.

He was taken to the hospital on 14 August, needing treatment for burns, after he collapsed unconscious against a radiator at his sheltered accommodation home in Woodford Green, Essex.

Assessed

Dr Ruth Brown warned the mistakes could be repeated

His condition was assessed by a triage nurse who decided he should be seen by a doctor within one hour.

However, a doctor had still not seen him at the time of his death.

He was found collapsed in a cubicle and pronounced dead 10 minutes later.

A post mortem examination showed Mr Rogers had died of an aneurysm.

The official report of the inquiry team says that Mr Rogers' long wait was not unusual for patients at Whipps Cross.

It says: "There are many points in the process of the management of his care where the system simply failed.

"None of the system failures in themselves were serious enough to result in the final outcome, but all contributed."

Not obvious

The report says that it was probably not obvious that Mr Rogers had suffered a ruptured aneurysm.

There are many points in the process of the management of his care where the system simply failed

Inquiry report

However, it says that if he had been seen earlier by a doctor, and the diagnosis made, it is possible that he might have survived.

The nurse who initially assessed Mr Rogers prioritised him correctly, the report says, but heavy demand from other patients made it impossible for him to be seen within one hour.

Given this, Mr Rogers should have been re-assessed, but this secondary assessment appeared not to take place. This may have led to staff believing that he was not seriously ill, and effectively putting him to the back of the queue.

The report says that the hospital's accident and emergency department should undertake an urgent review of the way patients are initially assessed.

Accountability

It also calls for new guidelines about what details nurses should include in a patient's record, and for the hospital to make it clear which nurse has prime responsibility for a patient.

The trust is also urged to review the way it manages available beds to reduce the number of patients waiting hours in casualty for a bed to become available.

Inquiry chief Dr Ruth Brown, a consultant in emergency medicine at King's College Hospital, said: "It is essential to recognise that the individual errors and omissions that occurred in this case might happen at any of our own hospitals and we recognise that we can learn valuable lessons from this case which are applicable to all trusts."

Peter Coles, chief executive of the Whipps Cross University Hospital NHS Trust, said: "We accept that the nine hours that Mr Rogers had to wait before being seen by a doctor was unacceptable, however busy the department was on that day.

"We need to ensure that patients who come to our hospital as emergencies take priority and the whole system responds to their needs."

The family of Thomas Rogers said they hoped no-one else would have to suffer as they did.

Alan Rogers, eldest of his three sons, said: "We hope that our efforts to date will minimise the risk of this happening to another family."