An investigation by Manchester University and Central Manchester hospital trust yesterday said no systematic search took place for Louis Hughes, 69, after his family reported him missing on the evening of 8 July.
Mr Hughes, a longstanding outpatient who had undergone heart bypass surgery at the infirmary, probably suffered a sudden heart attack after eating lunch in a hospital restaurant. 'There was no evidence to suggest that he suffered any pain or distress,' the inquiry report said.
His family said Mr Hughes had a lump on his wrist which was the subject of an examination of surgery students; none of the volunteers was entered on a register.
The surgery examinations were held in an empty ward while the surgical ward normally used was being refurbished.
'Mr Hughes was seen on numerous occasions throughout the morning by students and staff,' the report said.
'There is no suggestion that the examinations were physically or mentally taxing for volunteer patients. At no time during the day did any of the patients complain of feeling unwell.'
Some patients did not return to the ward after lunch. 'It was not unusual for patients to leave as a result of boredom or becoming fed-up with repetitive examination. Fewer patients did not cause undue alarm,' the report said.
Mr Hughes's family reported him missing to police at 10pm. A series of checks with the hospital proved fruitless because staff on duty had no list of volunteers for surgical examinations and Mr Hughes had not been admitted to an infirmary ward.
Only when a sister from a surgical ward began her shift at 4pm on 9 July did the hospital become aware that surgical examinations had been held. Neil Parrott, a senior lecturer, was finally contacted at 8pm, and confirmed that Mr Hughes's name was on the list of volunteers. His body was found an hour later.
No disciplinary action against staff was recommended by the inquiry, and Mr Hughes's family said it did not want individuals held responsible for the failure to find him.
The report said liaison between the university and the hospital should be improved, along with internal security procedures; volunteer patients should be signed in and out of the examination; and lists should be available to duty staff, including the reception desk, security officers, and nurses. The trust said all the recommendations will be implemented.