A coroner has identified six key failings and several "shortcomings" in the care of a man who died within hours of being discharged from Stafford Hospital.
John Moore-Robinson, from Leicester, had suffered a ruptured spleen in a mountain biking accident - but doctors failed to spot it.
A second inquest in the death of a Stafford Hospital patient, who was sent home with an undiagnosed ruptured spleen, will resume later today.
John Moore-Robinson died in 2006 after a doctor failed to spot the ruptured spleen following a mountain bike accident.
Coroner Catherine Mason adjourned the inquest in April and requested that Mid Staffordshire NHS Foundation Trust, who run the hospital, make the necessary staff available as witnesses.
After the first inquest in 2007 an internal report from the hospital said Mr Moore-Robinson's treatment could have been negligent.
Yesterday the inquest heard from a Mid Staffs nurse, who said the trust was understaffed at the time of Mr Moore-Robinson's death.
Today the inquest will hear from Dr Ivan Phair, a consultant in the A&E unit, who wrote the trust's internal report. In his report he said Mr Moore-Robinson should have had an ultrasound examination, which would have identified the damage to his spleen.
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