A wife is “frustrated” with the conclusion of an inquest into her husband’s death, calling for the Sutton hospital he died in to make big changes.

Phillip Morris, 48, died in Spire St Anthony’s Hospital while recovering from gastric sleeve surgery.

An inquest into his death revealed multiple errors were made in the run up to his death such as blood tests being taken late and life-saving equipment not working.

His wife Dana, 48, had hoped one of the findings to be neglect on the hospital’s part, however this was not part of the coroner’s conclusion.

She said: “I’m a pretty measured person but when I look at this, I think that unless Spire St Anthony’s does a total overhaul, they are not going to connect those things up to make sure things are corrected.

“Because the coroner didn’t do a prevention of future deaths report, I can’t say I walked away with any evidence that true actions had happened.

“I was frustrated by the result. Our barrister had put in for neglect, the coroner gave her definition that somebody had been starved or not given safe shelter.

“But, I look at it and well Phil was so poorly he couldn’t keep water down and on the Thursday they had allowed him to escape the building and I kind of think, well, does that not meet the criteria then for neglect?

“At the same time I’m very grateful for all the preparation that the coroner and her officer did, it was phenomenal.

“I did just feel frustrated that without a prevention of future deaths report and without the verdict of neglect that it leaves the door open for this to happen again.”

A five-day inquest into the dad-of-one’s death was held from February 5 – 9.

He died on December 10, 2021 in St Anthony’s Hospital after pieces of potentially life-saving equipment were found to be not working or not connected properly as he was being resuscitated.

Senior Coroner Ormond-Walshe said: “On the balance of probabilities, it is likely that Mr Morris would have survived the emergency intubation procedure had a correctly attached and working EtCO2 module been in use when assessing the front of neck airway, or at the time that the airway was first fashioned.”

Despite this, Senior Coroner Walshe did not conclude that Phillip’s death was down to neglect.

She said: “To give a neglect conclusion, I would have to find there was a clear connection between neglect and the death. I’m not returning a neglect conclusion.”

Phillip had considered this to be a “small serious risk for a life-changing reward” and researched the procedure extensively.

Senior Coroner Walshe concluded: “The deceased died suffering complications of an emergency procedure carried out, in turn, to treat complications post bariatric surgery.”

Dana urgently wants the hospital to make changes so that these errors do not cost someone else their life.

She added: “Sheila Enright, director of clinical services, said at the inquest that blood tests not being taken on time has not been her experience.

“It may not have been but what are they going to do to make sure this doesn’t happen again because this has now happened.

“And, it wasn’t like it was just one blood test not delivered on time - there were multiple blood tests throughout the week that hadn’t been taken on time.”

Phillip was a writer, university lecturer and a trained actor and his wife describes him as “funny, focused and determined” adding that he was “the most intelligent man that I had ever met”.

In a statement heard by the Coroners Court on February 5, Mrs Morris explained that Phil suffered from severe obstructive sleep apnoea, requiring him to sleep with CPAP (Continuous Positive Airway Pressure) every night.

He was also a type II diabetic and had allegedly been thinking about how to lose weight for a long time.

Dana said that he had decided to go through with this surgery for the health benefits being a lower weight would give him.