A father-of-three died after a number of failings in his care at Medway Maritime Hospital, a coroner has ruled.

A three-day inquest into the death of Anthony Baker, from Sheppey, was held at Archbishop’s Palace, Maidstone, this week.

The 61-year-old died on March 31 last year after suffering a cardiac arrest followed by multiple organ failure.

It came after junior doctors and nurses failed to recognise signs of internal bleeding and to diagnose a type of blood clot called a false femoral aneurysm.

The self-employed driver trainer was admitted to Medway Maritime Hospital on March 22 and treated for cardiac symptoms.

Later that day, he was admitted to intensive care for kidney problems. Over the course of the next eight days he responded well to treatment and was transferred from intensive care to the ward on March 28.

Shortly after, he developed severe pain - which could not be eased by morphine and other painkilling medication - and other signs of bleeding.

These signs went unrecognised until March 30, when he suffered a cardiac arrest. Emergency surgery was performed to treat a ruptured false aneurysm in his left femoral artery, where a massive haematoma, or blood clot, was discovered.

Mr Baker returned to intensive care where he suffered multiple organ failure. A decision was made to withdraw treatment and he died.

It was found that the false aneurysm had been developing from the time the pain started, but the nursing and medical staff failed to recognise symptoms of pain, a drop in blood pressure and poor urine output.

Shortly before the inquest, Medway NHS Foundation Trust, which has been in special measures since July 2013, accepted that there were failures in Mr Baker’s care which caused his death.

"Our lives have been ripped apart since he was stolen from us. It is so difficult to accept his death, largely because it happened as a result of others' mistakes" - Jane Baker

The inquest heard there was a lack of awareness on the ward about the complications associated with angiography - a type of X-ray - and appropriate monitoring for such complications. There is still no list of potential complications available to ward staff.

There were no cardiology consultants available at weekends, which has since changed, and there was a culture of junior doctors and nurses at the hospital not wanting to escalate problems to superiors or call people out of hours.

Steps have been taken to encourage reporting of concerns as soon as possible which are included in the Trust’s induction programme.

Coroner Kate Thomas, said: “Anthony Baker underwent an angiogram and stenting procedure following which he developed a false aneurysm which ruptured.

"Although he displayed a number of symptoms from which a rupture could have been diagnosed over a period of 15 hours, there was a failure to do so.”

Mr Baker’s widow Jane Baker said: “Tony, my husband of 31 years, was my world. He was a fabulous father to our three sons, Andrew, 30, Stephen, 28, and Christopher, 17, and our lives have been ripped apart since he was stolen from us.

“It is so difficult to accept his death, largely because it happened as a result of others’ mistakes.

“I am relieved that the coroner has identified failings and I sincerely hope, as I know would Tony, that as a result of the changes made at the Trust no other person has to go through this trauma again.”

Following Mr. Baker’s death, it was discovered a Patient Case Safety Review, which decides if an incident is serious and requires further investigation, was completed by a matron but the medical director did not approve the incident as serious and so a full investigation did not happen.

The PCSR, completed in April 2014, was withheld from the family until February this year.

Dawn Treloar, medical negligence solicitor at Hodge Jones & Allen, representing the Baker family, said: “It is essential that lessons are learned and incidents such as this are avoided in the future.”

A spokesman for the hospital said: “The trust deeply regrets the death of Mr Baker.

"Our care was not as it should be and the trust has admitted liability in this case. We continue to be in discussions with Mr Baker’s family and legal representatives.

"The coroner in this case was satisfied that the trust had speedily identified the failings in Mr Baker’s care following his death and had already taken robust steps to rectify these deficiencies.

"The coroner made clear at the inquest that she was satisfied that the remedial measures put in place by the trust were sufficiently robust to minimise the chance of anything like this happening in the future.”