A coroner has concluded that gross failure by a hospital contributed to the death of a man whose severe constipation meant he had to have 10kg of faeces removed from his bowels.
Richard Handley, 33, who had Downs Syndrome and was from Lowestoft, Suffolk, died from a cardiac arrest in November 2012.
A post-mortem examination found that his bronchi and nasal passages contained gastric contents and it was likely that he had choked on his vomit due to a bowel obstruction, the law firm acting for his family said.
It said the inquest found that due to a lack of careful monitoring of his condition, he developed severe constipation and his abdomen became so distended he had to have surgery to remove the build up of faeces.
Recording a narrative conclusion, Senior Coroner for Suffolk, Peter Dean, made a finding of gross failure to the actions of Ipswich Hospital, part of the Norfolk and Suffolk NHS Foundation Trust.
The inquest heard the hospital did not respond appropriately to Mr Handley's increased Modified Early Warning Score (MEWS), designed to flag any deteriorating changes in a patient's condition.
Changes to Mr Handley's diet and the decreased monitoring of his bowel movements at his care home also contributed to his worsening constipation and ultimately led to his death, law firm Hodge Jones & Allen said.
Mr Handley, who lived with his family until he went to live in the care home at the age of 19, was suspected of suffering from Hirschsprung's disease, a condition which causes chronic constipation.
This meant that part of his care involved careful monitoring of his diet and bowel movements, Ipswich Coroners' Court heard.
In 2010 the status of the care home changed, and it appears that, unknown to his family, the knowledge of his specific care needs was lost and he went on to develop severe constipation.
Mr Handley's mother, Sheila Handley, said: "Given the evidence we've heard in court, and the gross failures and missed opportunities noted, we are profoundly disappointed that the coroner felt unable to make a finding of neglect.
"The coroner did, however, recognise that without our diligence and persistence many of the reviews into Richard's death would not have occurred and the inquest would not have been able to explore the extent of the failings in his care.
"Richard was wholly reliant on health and social care services to exist, and now he doesn't.
"We will now take time to digest what we've heard today and consider next steps with our lawyer."
Nina Ali, a clinical negligence partner at Hodge Jones & Allen, said: "I echo the family's disappointment at today's findings.
"Given the weight of evidence presented, it is difficult to understand how the failure to deliver Richard the package of care he required was not neglect. We will now spend some time considering our next steps."