John Hubley was an acclaimed expert in developing world health issues
John Hubley believed and, perhaps more poignantly, trusted in the NHS.
He was 58 years old and an expert in public health in the developing world. He fell ill with gall bladder problems during a trip to Barbados in 2006.
Dr Hubley opted to delay the surgery he needed to remove his gall bladder until he was back in the UK, where he placed his faith in the public health service.
But he was not treated in an NHS hospital.
In January 2007, Dr Hubley chose to go to a private clinic contracted by the NHS to carry out routine, low-risk procedures.
There are around 40 such Independent Sector Treatment Centres (ISTCs) in the UK and they were a key policy of the "new NHS" that was meant to offer good service and limit wait times.
Bled to death
During keyhole surgery at the Eccleshill Treatment Centre in Bradford, a major vein was ruptured.
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Panorama: Dying to be Treated?, BBC One, Wednesday, 30 September at 2000BST
While haemorrahage is a known complication of the operation, the clinic had no blood on site and no blue light fast courier system to get any to the clinic.
Instead, a porter made a 40-minute round trip in his own car to pick up the supplies from the nearby Bradford Royal Infirmary.
Blood was not the only thing missing that morning. The centre lacked some of the basic equipment to help stem the bleeding.
The surgeon performing the operation did not have access to a phone in the operating theatre to call for help when it became clear that he was losing his patient.
When blood finally arrived, it was too cold to use and the clinic did not have the equipment to warm it - the theatre staff resorted to using bowls of hot water - costing more critical time.
Two more blood runs were made, but by then it was too late and Dr Hubley died of multi-organ failure the next day.
At the inquest, the coroner ruled that the death was due to misadventure, aggravated by neglect and said that on the balance of probabilities, had the surgery been conducted at the nearby hospital, he would have survived.
In his summation, the coroner was scathing, stating: "Surgery is about safety, not what can be got away with."
Bren Neale, Dr Hubley's partner, told the BBC's Panorama: "It's a real irony because he had enormous faith in the NHS.
"He was working in parts of the world where there was no clean water, where there were very few sanitation systems in place and so he thought we had such a wonderful system here."
Ms Neale waited two years for details of Dr Hubley's death to be made public at the inquest.
PRIVATE TREATMENT ON THE NHS
Department of Health announced creation of Independent Sector Treatment Centres in 2003
Private clinics would perform common, basic elective procedures on NHS patients
Initial goal was to have the private clinics perform 250,000 operations over five years
She said she thinks people agreeing to undergo surgery in ISTCs do so thinking the same level of care will be immediately available to them as they would find within an NHS hospital.
"I think there is a general perception that the standards of safety, patient care and so on are really cast iron across the NHS or indeed outposts such as this one."
The Department of Health told Panorama that ISTCs were subject to a robust system of safety checks and patients could expect the same standard of care as in the NHS.
They said that the clinics had treated hundreds of thousands of patients successfully and succeeded in slashing long waiting lists and reducing suffering.
Dr Jonathan Fielden, Chair of the Consultants and Specialists Committee of the British Medical Association, said a death like this highlighted the key risk of outsourcing operations.
"There are risks that they don't get the continuity of care, the continuity when something goes wrong, the immediate access to pathology labs, blood banks
all the back-up that there is in a full NHS facility. An isolated treatment centre doesn't have that."
ISTCs came about in 2003 as part of the Labour government's push to drastically cut NHS wait times.
Private companies were contracted to carry out routine procedures such as keyhole gall bladder operations, hip and knee replacements and cataract surgeries.
To get private companies on board, they were paid around 10% more than what the NHS would be paid for the same procedures.
At the time of Dr Hubley's death, Eccleshill was owned by Nations Healthcare, which has since been taken over by Circle.
Of the 22,000 procedures carried out at Eccleshill, Dr Hubley was the only death.
Tracey McNeill, of Circle, told Panorama that at the time of Dr Hubley's death, there was a tried and tested protocol system in place for getting blood to the clinic in an emergency.
"It was felt and deemed safe by all of those who reviewed that system, including regulators," she said.
The operating theatre had no phone, blood or equipment to warm blood
Ms McNeill said Dr Hubley's death was a "very catastrophic event which is extremely rare" and added that lessons had been learnt.
Eccleshill immediately suspended keyhole gall bladder operations after the death and carried out a thorough review of their services. The coroner accepted that there were no ongoing failures at the clinic.
Ms McNeill said: "What happens in healthcare when you have events like this is that you review them, you learn from them and so there is now blood on site."
Health minister Mike O'Brien told the BBC in a statement that the death was "deeply regrettable".
"This incident was thoroughly investigated and new procedures have been put in place to reduce the chances of incidents like this happening again. New national guidance was also issued by the National Patient Safety Agency."
Ms Neale said the list of failings that were revealed, from the lack of theatre equipment, to the failure to keep blood on site, to the inaccurate estimate of how long it would take for blood to be collected and delivered, added to her sense of loss.
"I think it is always a tragedy to lose someone that's close to you and when it's sudden that is another terrible blow, but to lose someone when it then becomes clear that their death could have been prevented leads to a deep sense of injustice, which I have felt and so have John's children and the rest of the family."
Dying to be Treated? - a Panorama special, BBC One, Wednesday 30 September, at 2000 BST.