A conclusion of misadventure has been recorded on a Rhos-on-Sea pensioner who died after an operation to  remove a bowel blockage went wrong.

But at the end of a three-day inquest in Ruthin the family of 81-year-old Arthur Price Hughes said that Dr Georgios Akratidis, the locum surgeon who carried out the operation, was not wholly to blame, referring to “a perfect storm of inaction”.

Dr Akritidis, who was sacked immediately after the tragedy in October, 2014 ,  had been working at Glan Clwyd Hospital for just two months and had had restrictions  because of concerns raised by theatre staff on four previous occasions.

One of the conditions was that he be supervised, but senior consultant Andrew Maw told the inquest that he was not happy to learn that he was  delegated to supervise Dr Akratidis that day because he had a heavy workload.

However, it had been made clear to him that the supervision merely meant that he was available to help if needed. As it happened, he was called to another emergency in another theatre during Mr Hughes’ operation.

He returned when the problem arose, and completed the surgery which Dr Akratidis had begun. Mr Hughes has lost over four litres of blood from damaged veins, and Dr Akratidis accepted that only he could have caused the damage, possibly through traction while trying to gain access to the site in his abdomen.

“I was there to help if necessary and if required at any point,” said Mr Maw.

Ralph Anstrum, an experienced colo-rectal surgeon called as an independent expert to examine the circumstances, said Mr Maw appeared to have been overstretched, but the operation was one which Dr Akritidis should have been capable of doing himself.

The inquest heard that only two of the locum’s three references had been taken up and none of them had been spoken to.

Recording a conclusion of misadventure, John Gittins, coroner for North Wales East and Central, said he could not be sure whether the damage had been caused by “pure error” or by a complication which had arisen.

He said he had originally been concerned about the taking up of references but had been assured that the Betsi Cadwaladr University Health Board had since introduced a protocol to that effect.

However, he said he intended to issue a Regulation 28 report to prevent future deaths  expressing his concern about the lack of ongoing assessment and mentoring for new appointees, adding: “It might not have made a difference in Mr Hughes’ case.”

After the hearing the family of Mr Hughes, of Penrhyn Avenue, Rhos-on-Sea, described him as “one of the cornerstays of our family”, who died two days before he had a chance to see his first great-grandchild.

“As a family we believe that although Dr Akritidis said it was his actions that led to Taid’s death the fault was not wholly his,” they said.

“He was put in a difficult position and unfortunately  did not have the courage to speak up. The senior staff failed to recognise and act on the concerns raised in a way that would ensure patients’ safety.

“The initial recruitment appears flawed and to some extent has been improved, but we believe further work on this is required.”

Their statement continued: “There was a distinct lack of training in terms of actual management, risk assessment, datix and support mechanisms for doctors in difficult and a lack of communication amongst the teams meant that the most senior staff  appeared unaware of the concerns raised.

All of this led to a perfect storm of inaction and to the tragic events which unfolded.”

The family paid tribute to the staff in the Intensive Therapy Unit for the support they received in Mr Hughes’ final days.

Dr David Fearnley, Executive Medical Director at Betsi Cadwaladr University Health Board said:

“On behalf of the Health Board, I wish to express our condolences to Mr Price Hughes’ loved ones and to apologise for the failings identified.

“We accept the coroner’s findings and can provide assurances that since 2014, many of the systems and processes highlighted have been significantly improved. Notwithstanding this, we recognise the remaining concern of the Coroner and will of course respond to provide the necessary assurance for the Coroner and Mr Price Hughes’ family.