Dying man branded a 'drama king', inquest hears Staff nurse Rhian Grapes alerted Dr Olamide Eso to Mr Tatchell's pain. She told the hearing: "I told the senior house officer who referred to him as being a drama king." Dr Eso "categorically" denied the allegation, adding: "That's just not how I would speak about my patients." But the concerns over the patient's pain were shared by ward manager Sally Lewis became so concerned she went over Dr Eso's head by contacting the surgeon who carried out the operation, the court heard. Miss Lewis said: "I didn't feel the doctor looking after him had assessed Ron's condition enough." Blood samples taken at 6.30am were marked "urgent" but the results were not received until around 11.55am. Surgeon Declan O'Doherty, who carried out a review of the treatment, told the hearing: "The whole thing was just dysfunctional. At no stage did anyone actually know what his state was - I think there's been effectively a whole system failure. Mr Tatchell, of Bridgend, South Wales, died of hypovolemic shock as a result of haemorrhage following spinal surgery. Cardiff assistant deputy Mr Woolley ruled his death was a result of neglect by hospital staff. He said: "There was a continuous sequence of shortcomings. There's a link between the failure and Ron's death. So I do find there has been neglect. The Cardiff and Vale University Health Board yesterday apologised to Mr Tatchell's widow Angela, 66, and his two sons Steven, 36, and Matthew, 42. Director of nursing Ruth Walker said: "Words are of little comfort at such a distressing time but we would like to offer our sincere and unreserved apologies to Mr Tatchell's family. The failures in his care are absolutely unacceptable. While no one individual is to blame, it is clear that the system let down Mr Tatchell, with tragic consequences. We have already undertaken a full and in-depth investigation into Mr Tatchell's care which we shared with his family and the coroner ahead of the inquest. We will review urgently the detail of his findings to make sure that we address fully all of the failings identified.