Thomas Rogers died after waiting hours
The review found that a series of management failings were to blame for the failure of Thomas Rogers to receive adequate care.
Mr Rogers died after he was left for nearly nine hours on a trolley at the Accident and Emergency Department of Whipps Cross University Hospital, in Leytonstone, east London.
The hospital commissioned Dr Ruth Brown, a consultant in emergency medicine at King's College Hospital, to head an inquiry into the case.
Mr Rogers, 74, was taken to the hospital on 14 August, needing treatment for burns, after he collapsed unconscious against a radiator at his sheltered accommodation home in Woodford Green, Essex.
Assessed
His condition was assessed by a triage nurse who decided he should be seen by a doctor within one hour.
However a doctor had still not seen him at the time of his death, some eight and half hours after his arrival.
When a nurse went to check at 0210 BST on 15 August he was found collapsed in a cubicle and pronounced dead 10 minutes later, despite the efforts of an emergency resuscitation team.
A post mortem examination showed Mr Rogers had died of an aneurysm.
The official report of the inquiry team says that Mr Rogers' long wait was not unusual for patients at Whipps Cross.
It says: "There are many points in the process of the management of his care where the system simply failed.
"None of the system failures in themselves were serious enough to result in the final outcome, but all contributed."
Not obvious
The report says that it was probably not obvious that Mr Rogers had suffered a ruptured aneurysm.
The nurse who initially assessed Mr Rogers prioritised him correctly, the report says, but heavy demand from other patients made it impossible for him to be seen within one hour.
Given this, Mr Rogers should have been re-assessed, but this secondary assessment appeared not to take place. This may have led to staff believing that he was not seriously ill, and effectively putting him to the back of the queue.
The report says that the hospital's accident and emergency department should undertake an urgent review of the way patients are initially assessed.
Accountability
It also calls for new guidelines about what details nurses should include in a patient's record, and for the hospital to make it clear which nurse has prime responsibility for a patient.
The trust is also urged to review the way it manages available beds to reduce the number of patients waiting hours in casualty for a bed to become available.
The report says: "During the interviews with A&E staff, we detected a sense of resignation to the long waits, both to be seen by a doctor, and for beds.
"This was as if the staff saw no point in continuing to try to solve the problem.
"We are not convinced that the senior managers within the department were working together to solve the issue."