The heads of an NHS trust were told to apologise in person to the parents of a cancer patient who bled to death after a breathing tube was inserted incorrectly in his neck. The Public Services Ombudsman for Wales, Peter Tyndall, criticised the Cwm Taf NHS Trust severely, saying that the actions of its staff “directly resulted” in the premature death of Myron Hall, a 47-year-old electrician.

Mr Hall’s parents called for the police to investigate whether the trust, in South Wales, or any individuals should face criminal charges.

Mr Hall was referred to the former North Glamorgan NHS Trust in September 2006 by his GP because of a suspicious lump in his neck.

It took three months to diagnose a malignant tumour and doctors decided the best way to treat him was to remove half his tongue.

A tracheostomy tube was put in his windpipe to help him to breathe, but surgeons stopped the operation when they found that the tumour had spread too far.

Mr Hall later began bleeding from a replacement tube that was inserted in the wrong place while he waited to be transferred to a specialist cancer centre for chemotherapy.

The wound was stitched when it was noticed the tube was not in the right place, but four days after returning to the ward Mr Hall suffered a “catastrophic bleed” caused by the tube wearing through the wall of an artery.

He died despite the efforts of staff at the Royal Glamorgan Hospital, in Llantrisant, to resuscitate him.

His parents, Denzil and Janet Tilley, of Porthcawl, arrived at the hospital seconds before he died. In the report, Mr Tilley compares the scene at his son’s bed to a “horror movie”.

The report says the initial investigation of Mr Hall’s tumour was “slow and inadequate” and the nursing he received in relation to his tracheostomy “fell below a standard one could reasonably expect”.

Although he was admitted to hospital with a very serious and potentially life-threatening condition, Mr Tyndall says he has “no doubt whatsoever that the actions of the Trust directly resulted in Mr H’s premature death”.

“Not only was Mr H’s death avoidable, it occurred as a direct result of the action (or inaction) of Trust staff and should not have happened,” the report adds.

Mr Tyndall said: “Whilst no amount of apologising can compensate a parent for the loss of a son in such horrendous circumstances, I have nevertheless recommended that both the chair and the chief executive of Cwm Taf Trust should provide Mr H’s parents with an unequivocal apology for the failings that occurred during the care of their son.”

Cwm Taf Trust, which took over from North Glamorgan and the former Pontypridd and Rhondda Trust, told the Ombudsman it could not meet his request for an apology in person but would write to Mr Hall’s parents — a stance he calls “unreasonable”.

Mr and Mrs Tilley’s solicitor, Astrid Coates, said: “Failures by the trust led to the death of Mr Hall and his family want to know that this will not happen to someone else’s son.

“We will be calling upon the coroner to ascertain exactly what action has been taken by the Trust to prevent similar fatalities and to withhold this information when it may assist Mr and Mrs Tilley in dealing with their grief is inexplicable.”

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