An NHS trust which failed to adequately supervise two doctors ahead of a patient's death has been criticised.
The doctors were employed in the trauma and orthopaedic department
Southampton University Hospitals NHS Trust admitted under the Health and Safety Act that it had not properly managed the senior house officers.
Amit Misra and Rajeev Srivastava were working at Southampton General Hospital in June 2000 when Sean Phillips, 31, died after routine knee surgery.
He suffered toxic shock syndrome. The trust will be sentenced on Tuesday.
At a sentencing hearing at Winchester Crown Court on Monday Hywel Jenkins, prosecuting, said that a "proper system of supervision and evaluation of junior staff at the hospital could have saved Mr Phillips' life".
Dr Srivastava was suspended from working for six months
"An adequate system would have increased the prospect of his deteriorating condition being brought to the attention of senior staff in time."
Mr Jenkins said if the hospital had organised daily visits by a specialist registrar for all patients "the chances of it [the condition] being missed would have been lessened".
The court heard a senior nurse wrote a letter to management on the day Mr Phillips died criticising the management structure in the department.
He added that a senior house officer (SHO) also wrote to management after he left the department, "raising concerns about staffing levels".
He described how the unit should have had 10 SHOs on any rota but instead normally there were only four or five with one on administrative duties.
This left one doctor to supervise 40 patients.
Mr Jenkins provided a list of improvements the trust should make to provide adequate supervision.
Mr Jenkins added: "They need a system that doesn't expose the patients to that risk."
The two doctors failed to diagnose the condition and the 31-year-old father-of-one from Southampton died.
In 2003, both doctors were convicted of manslaughter by gross negligence following a trial at Winchester Crown Court.
Both were sentenced to 18 months' imprisonment, suspended for two years.
Last year, the GMC suspended Misra, 35, from working for a year and Srivastava, 40, for six months.
In a rare move, the Crown Prosecution Service charged the trust following the trial.
At an earlier hearing, the trust pleaded guilty to failing to supervise the doctors in the trauma and orthopaedic department.