A retired NHS consultant died by neglect on an understaffed hospital ward, an inquest has found.
Dr David Gordon-Nesbitt, 84, suffocated when a drainage tube was left closed following an operation to remove bowel construction at Queen Elizabeth the Queen Mother Hospital (QEQM), Margate, Kent.
It later emerged that the ward was meant to have five nurses on but only had three.
They were two agency nurses and a student nurse who should not have been left on her own to tend to Dr Gordon-Nesbitt.
The doctor overseeing the ward was off-site and only reachable by phone, the inquest was told.
Dr Gordon-Nesbitt died when a mistake on an understaffed ward led him to inhale stomach fluids into his lungs, it was said.
An assistant coroner said Dr Gordon-Nesbitt died because of a failure of basic nursing clinical care, rather than a complex or sophisticated medical procedure.
The family of the retired consultant paediatrician said he was in "really good health for his age."
The East Kent Hospitals Trust accepted the coroner's findings and apologised to Dr Gordon-Nesbitt's family.
The coroner said staffing levels contributed to the neglect.
Dr Gordon-Nesbitt's daughter Rebecca, from Ramsgate, said: "Dad was in really good health for a man his age. This was an issue he'd dealt with for years, and it should not have killed him.
"On the weekend Dad died, there were too few experienced nursing staff available to work, and a dreadful mistake was made in his care.
"My father gave 45 years of his working life to the NHS. It is horrifying that he should die like this.
"Ultimate responsibility lies with the government for underfunding the NHS and for withdrawing the nursing bursary."
At the time of his death, there were only three nurses on the ward with 32 patients.
Of the three nurses, two were agency staff and one was a newly-qualified junior nurse named as the nurse-in-charge.
Mr Gordon-Nesbitt was admitted to QEQM on October 21, suffering from a bowel obstruction which had recurred several times following an operation to remove a tumour from his bowel in the late 1990s.
As usual, he was to be kept in the hospital under observation until the issue was resolved and had a standard operation to reduce swelling in the bowel.
Oral dyes show the blockage on an x-ray, and one was given to reduce the swelling by absorbing water from the bowel.
During the standard operation, a nasogastric tube was fitted, a very thin tube running from the nose into the stomach to remove stomach fluid and the dye.
When he was sent for an x-ray on Saturday 23 October 2021 the tube was spigotted, or clamped. Nobody unclamped the tube and when he returned to the ward the digestive juices and dye could not drain.
Fluid built up until the retired doctor vomited. That night his lungs filled with fluid and he developed sepsis, went into cardiac arrest and died.
The cause of death was aspiration pneumonia, caused by an acute small bowel obstruction as a part of a recurrent adhesion-related small bowel obstruction.
Ischaemic heart disease and a previous subarachnoid haemorrhage were noted as background.
Assistant Coroner Catherine Wood said not unclamping the tube was a gross failure, greater in magnitude than medical negligence.
She said it amounted to a failure of basic nursing clinical care, and removing the spigot would have prevented Dr Gordon-Nesbitt's death and saved or prolonged his life.
She added low staffing levels on the ward contributed to the consultant's death.
Ms Wood asked the East Kent Hospitals Trust to confirm within 14 days that the management team will investigate staffing levels, specifically what help the hospital site manager could have offered.
Acknowledging the national shortage of NHS staff, Ms Wood said further support and supervision is required from the hospital site team - even if staffing levels improve.
Rebecca was represented by Leigh Day's medical negligence solicitor Frankie Rhodes, who said her father would not have died if the nasogastric tube was unclamped.
Ms Rhodes said: "A finding of neglect in a case such as this is extremely rare; the bar for such a conclusion in an inquest is very high, but the coroner was clear that there was sufficient evidence for this and that all of the tests were met.
"Dr David Gordon-Nesbitt would not have died if his nasogastric tube had been unclamped on that Saturday in Queen Elizabeth the Queen Mother Hospital.
"The coroner found that the shortage of staff on the ward contributed to the circumstances that led to the doctor's death."
Sarah Shingler, Executive Chief Nursing and Midwifery Officer for East Kent Hospitals, said the trust "fully accepts" the finding and conclusion of the inquest.
She said: "We apologise unreservedly to Mr Gordon-Nesbitt's family for the failings in his care.
"[Since the incident], we have employed more nurses, increased leadership support on each shift, and strengthened patient safety procedures on the ward."
