A health board has made improvements to its appointments system after the death of a man in Swansea.
Mitchell Joseph, 33, a dad-to-be who never got to meet his daughter, died on 14 January 2018 after suffering a cardiac arrest while playing football.
The inquest heard the incident occurred during a match at Mynydd Newydd playing fields in the Penlan area of Swansea.
An inquest conclusion on Wednesday heard Swansea Bay University Health Board has made improvements after an appointments “mix-up” prior to Mr Joseph’s death.
Assistant coroner Aled Gruffydd said Mr Joseph had “conceived a daughter that he sadly never got to meet”.
Mr Joseph underwent open-heart surgery in May 2017.
Clinicians told the inquest that surgery “would have been inevitable at some point”.
Mr Joseph was diagnosed with a heart murmur in 2012 after attending a clinic following an accident at work.
Pragmatic decision
Mr Gruffydd said he believed Mr Joseph “made a sensible and pragmatic decision” to undergo surgery, based on the information he had at the time.
“Ultimately, it was not the operation that ended Mitchell’s life,” he added.
Mr Gruffydd concluded that a “mix-up in the appointment system was a failing”.
The inquest heard Mr Joseph had been invited back to see his clinician but that he never received written confirmation of the appointment.
The assistant coroner said this could have been a “missed opportunity to increase dose” of medication.
“However, I cannot state that these opportunities would have prevented death,” he added.
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Mr Gruffydd said he could find “no human culpability” in Mr Mitchell’s death and returned a conclusion of natural causes.
“The health board have put in place improvements in the system to reduce the risk of future deaths occurring as a result of this particular issue,” he said.
In conclusion, the assistant coroner conveyed his condolences to Mr Joseph’s family.
