A seriously ill patient needing daily kidney dialysis at home was left for three days without treatment – despite being in hospital.
Andrew Wilson, who was under the care of the renal unit at Kent and Canterbury Hospital, died 11 days later, aged just 51.
Assistant coroner Alan Blunsdon said although the lack of kidney treatment did not contribute to his death, questions must be asked as to why he was left with no dialysis for three days.
Health bosses however insist he did not need the dialysis while he was in hospital and his kidney function did not deteriorate.
But Mr Blunsdon has demanded action from the East Kent Hospitals Trust, which is responsible for the K&C, taking the rare step of issuing a Regulation 28 report to prevent future deaths.
“The evidence revealed matters giving rise to concern,” he said.
“In my opinion there is a risk that future deaths will occur unless action is taken.”
Mr Wilson, who developed chronic kidney disease and later cardio-renal failure in February 2015, was receiving peritonial dialysis each night at home, which was outsourced by the K&C’s renal unit to a private organisation with specially trained staff.
He was admitted to Maidstone Hospital on July 20, 2015, suffering from blurred vision, considerable abdominal pain and unable to pass urine, and was diagnosed with sepsis.
But no one at the hospital or at any satellite renal unit in Kent could provide the dialysis and for the next three nights he went without the treatment.
According to the NHS website, when a patient does not have peritonial dialysis, waste products can build up to dangerous levels in the body as the kidneys do not function properly, causing unpleasant symptoms which, if untreated, can be fatal.
Mr Blunsdon said: “The explanation for the absence of dialysis provided by the East Kent Hospitals Trust is there are insufficient numbers of trained clinical staff available to provide peritoneal dialysis treatment at hospitals outside the renal unit at Canterbury.
“The outsourced staff would not be permitted to provide treatment within the hospital.”
Mr Wilson, who lived in Maidstone, was eventually transferred to the Kent and Canterbury on July 23, 2015, and dialysis was given.
He died from sepsis on July 31.
Mr Blunsdon said while the lack of dialysis did not cause the death on that occasion, the absence of any arrangements to provide the treatment at hospitals other than the renal unit at Canterbury is a serious concern.
He added there was an absence of knowledge with clinicians at Maidstone Hospital to arrange the dialysis or transport the equipment from the patient’s home to the hospital.
A spokesman for East Kent Hospitals said there treatement would not have been carried out at the hospital in any case due to risk of infection.
“Peritoneal dialysis is only suitable for a very small group of patients with chronic but stable kidney disease dialysing at home," she said.
"It would not be good practice to provide this service for any patient staying in hospital because the nature of the procedure means the risk of infection is too great within a hospital environment.
“Therefore, alternative treatments are offered for patients staying in hospital on established peritoneal dialysis should their kidney function deteriorate; however this was never required by Mr Wilson.
“In this case, the trust would have supported Mr Wilson using haemodialysis or haemofiltration if his kidney function was deteriorating. There was never any omission in his care.
“The low numbers of patients on peritoneal dialysis in Kent mean there are a limited number of staff who can maintain their clinical training in peritoneal dialysis.”