An inquest has recorded a verdict of death due to pneumonia in the case of a man with Down syndrome who had been re-admitted to Beaumont Hospital in Dublin in February 2011 and had suspected sepsis.
Bernard Wright, 57, had undergone a hernia operation at the hospital in January 2011.
Coroner Dr Brian Farrell asked that Beaumont Hospital review the issue raised by Mr Wright's family about communication over the administration of morphine.
Mr Wright was also deaf-mute and had developed Alzheimer's disease.
He lived at the Cara unit at St Michael's House in Belcamp for 15 years before his death in 2011.
After the inquest, the family thanked St Michael's House for allowing Mr Wright to die with dignity.
The Dublin City Coroner's Court heard today that Mr Wright was admitted to Beaumont Hospital on 29 January 2011 for the operation and was discharged back to St Michael's House on 4 February relatively well and improving.
However, Cara staff noticed a wound had become infected and he was re-admitted to the hospital four days later in a critical condition.
The family agreed that a "Do Not Resuscitate" order be instigated at Beaumont.
Mr Wright was transferred to St Michael's House where he died on 15 February 2011.
His sister Aileen Morrissey told the inquest that her brother was taken to Beaumont on 29 January 2011 with abdominal pain and had a hernia operation.
She said he was always fearful of doctors and hospitals so a family member was always with him.
Ms Morrissey said that while he was unable to speak or hear, he had his own language to speak to the family.
After the operation, he was groggy and was trying to touch his surgical wound.
She said he was discharged back to Cara in Belcamp and seemed to be improving.
Ms Morrissey said the next day staff at Cara were concerned about a wound and his condition after he returned from the hospital.
Mr Wright was brought to Beaumont Hospital's Emergency Department on 8 February. He was very ill with a high temperature.
Staff asked Ms Morrissey what the family felt about resuscitation in the event of a cardiac arrest.
The family decided it should be "Do Not Resuscitate", but that all treatment that would help him be given. They also asked for pain relief.
They were told it could be antibiotics or pain relief, but not both, and they opted for pain relief.
The hospital insists that antibiotics were administered and said some of the wounds post-surgery may have been self-inflicted.
Ms Morrissey told the inquest that her brother was still "screaming" with pain.
She asked that he be given stronger pain relief, but was told morphine could only be given when the palliative care team arrived, but that would not be for 24 hours.
It was clear that Mr Wright was dying and as a result, the family decided he be moved to Cara at Belcamp by private ambulance, where he would get the pain relief.
Mr Wright died at St Michael's House on 15 February 2011.
Consultant general vascular surgeon at Beaumont, Professor Austin Leahy, told the inquest that Mr Wright had recovered very well from the operation.
He said before and after the operation, and on discharge, there was no evidence of chest infection.
Prof Leahy said Mr Wright would pull at the catheter when agitated and it had come out.
This may have caused a bruising that became infected on 7 February when he was back at St Michael's House. But he did not believe this was the cause of this death.
Prof Leahy believed that Cara was the best place for Mr Wright to recover.