A CORONER has found hospital miscommunication and system failures meant Bundaberg man James Patrick Talbot's swollen abdomen went undiagnosed and untreated before he died.
The 87-year-old was taken to the Wesley Hospital in Brisbane in late December 2013 after he became unwell while visiting family for Christmas.
His death certificate said he died from aspiration pneumonia, after inhaling vomit.
But Deputy State Coroner John Lock said in his findings, delivered this morning, that there were issues about medical management of Mr Talbot's bowel obstruction.
He found Mr Talbot had died of a strangulated bowel.
The day after Mr Talbot was admitted into hospital, a nurse noted that Mr Talbot's abdomen was "very distended" - swollen.
But when the doctor later examined him, this was not noted.
In his findings, Mr Lock said the doctor's practice, similar to other specialists, was not to read the nursing progress notes but rely on oral updates.
He also said Mr Talbot's daughter Deborah Croxford had tried to raise concerns with a nurse that her father was vomiting and had a swollen stomach.
She questioned why a CT scan of her father's head had been ordered when it was obvious his stomach was swollen.
The nurse did not inspect Mr Talbot's stomach, Mr Lock's findings said.
Mr Lock said a range of failures to communicate and to heed concerns due to a combination of system and human errors led to a missed diagnosis.
He also noted that if bowel obstruction had been identified it would have led to Mr Talbot being given palliative care because surgery was a high risk and not viable.
But, he said the critical issue was that Mr Talbot and his family did not get the opportunity to make such decisions.
"Mr Talbot could have been made more comfortable and his family could have been with him," Mr Lock said.
"Instead he died alone and in an undignified manner."
Mr Lock said that since Mr Talbot's death, the hospital had implemented a "Let us know" process for escalation of family and patient concerns.