A failure of basic medical care led to the death of a seriously ill factory worker who was neglected by doctors for three days, an inquest was told.
A bungled handover meant 53 year-old Alan Rogers was not regularly observed after his admission to Good Hope Hospital in Sutton Coldfield with severe food poisoning.
By the time he was treated, it was "too little and too late", said the Birmingham coroner, Aidan Cotter.
In a damning criticism of the hospital, Mr Cotter told the inquest at Sutton Town Hall that it was the second time in just seven days he had found neglect had played a part in the death of a patient at Good Hope.
Returning a narrative verdict on Mr Rogers, whose death was ruled as being from natural causes, Mr Cotter said he intended to write to the hospital's chief executive so appropriate action could be taken "to prevent further deaths".
"It seems to me there are clear failures in the way Good Hope Hospital dealt with Mr Rogers," said Mr Cotter.
"It seems to me that doctors should have been regularly reviewing Mr Rogers.
"He should have been regularly observed and somebody should have known who his consultant was.
"I do consider that failing to have a doctor looking at a patient over that lengthy period, when the patient is admitted as an emergency, amounts to a failure of basic medical care."
The inquest heard that Mr Rogers, from Tamworth, Staffordshire, was admitted on the evening of December 6 with severe food poisoning.
He was sent by his GP to Good Hope as an emergency case, after complaining of worsening abdominal pain, diarrhoea and dehydration. He was referred to the hospital's Emergency Assessment Unit where he was examined shortly after midnight by a medical team.
It was accepted by the hospital, said Mr Cotter, that Mr Rogers was seriously ill and something needed to be done as a matter of urgency.
The team, led by Dr Helen Chamberlain, requested the opinion of surgeons to rule out the possibility of cancer in his bowel.
"Another doctor contacted the surgical team," she said.
"Later that morning I was leaving the ICU and I was approached by the surgical senior house officer who said 'We've seen the patient and we'll be taking over his care' and as he was the only referral I had made I assumed she was talking about him."
In fact it turned out that the SHO was talking about another patient, the inquest heard.
No mention was made of what had taken place in his notes, and the mix-up meant that from then on, until December 11, he was not under the care of a consultant and was not seen by any doctor on December 8, 9, or 11.
Dr Chamberlain said she had a team of two "extremely junior doctors" with just two years experience between them, looking after 50 patients.
Mr Cotter suggested the trust was "not coping". "There are days it feels like that, yes", said Dr Chamberlain.
Mr Rogers was finally seen by a consultant on the afternoon of December 12, and he decided the patient needed an immediate sigmoidoscopy and enema.
But when treatment came, said Mr Cotter, it was "too little and too late" and emergency surgery to remove the bowel was aborted when the patient was too weak to cope with it. He died later that day.
Yesterday's hearing came just after a week after an inquest was told how Lily Martin, aged 71, from Tam-worth, died after an operation to remove her gall bladder. It appeared post-operative bleeding had gone unspotted for 11 hours following the procedure.
Mr Cotter returned a narrative verdict and identified seven serious failings in Mrs Martin's care.
After yesterday's inquest, David Bowden, medical director at Good Hope Hospital, said changes had since been made regarding patient notes.
"The Trust accepts that mistakes were made in Mr Rogers' care. Changes have been made to our procedure to try and ensure those mistakes can't be made again."
