A nurse who failed to raise the alarm when he found a patient cold and unresponsive made “bad decisions” and “panicked”, an inquest has heard.
Mohammed Jaafri, of Dyserth near Rhyl, died at Glan Clwyd hospital in April last year.
Ruthin coroner’s court heard Joseph Kamangire found Jaafri cold and unresponsive and decided he had died.
But he did not follow resuscitation guidelines and issue a “cardiac arrest” call to doctors.
Agency nurse Kamangire said: “I was panicked and, in the panic, I made some bad decisions I was sorry for.”
Betsi Cadwaladr University Health Board accepted resuscitation should have been attempted, and opportunities to provide further observations were missed.
On Tuesday the inquest was told that Kamangire had been “in and out” of Moroccan-born Jaafri’s room on the ward, checking his oxygen mask, on 21 April 2025.
He found the patient cold and not breathing at 06:30 GMT, and his death was confirmed at 07:25.
Coroner John Gittens said the former furniture dealer’s death was not expected, and there was not a “do not attempt CPR” request in place. He also said there had been no overnight tests or observations carried out.
Despite the failings in Jaafri’s care, “and for reasons which remain unfathomable”, the death was not reported to him by doctors at the hospital, nor the medical examiner, the coroner said.
Gittens added there had been a “significant deviation” from the expected standards of care and “missed opportunities”.
He recorded a narrative conclusion and is considering whether a Prevention of Future Deaths report is necessary.
Jaafri’s probable cause of death was given by the hospital and medical examiner as bronchopneumonia due to flu and frailty.