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But the Coroner says there is no evidence to support such a move and whilst the death was "sad and difficult" there is no one to blame.
Richard James McFelin died in Timaru Hospital on October 14, 2016.
His cause of death was chest abdominal sepsis.
In the lead-up to his death there had been a number of issues with the 81-year-old's feeding tube, including the stitches holding it in place being "cut".
After his death his family made a complaint to the Health and Disability Commissioner.
Coroner Marcus Elliot also opened an inquiry and his final report was released today.
In it he outlined the circumstances of McFelin's death and said while he sympathised with the family, there was no reason for him to demand changes in the elderly care sector as they had requested.
When he died, McFelin was a resident at Elloughton Gardens in Timaru, which is operated by Radius Care Limited.
The pensioner had previously suffered from laryngeal cancer and had been through radiotherapy in 1996 and a total pharyngolaryngectomy - the total removal of his larynx (voice box) and pharynx - in 2006.
He had an electronic larynx placed.
In March 2016 he was admitted to Christchurch Hospital with complications including a narrowing of his oesophagus.
It was after that hospital stay that he was admitted to Elloughton Gardens because he had a feeding tube inserted and needed nutritional support.
Initially there were no issues with the feeding tube but on August 24 he was back in hospital briefly when it became inflamed.
On August 28 he returned to hospital to have the tube reinserted and it was stitched into place by a general surgeon.
For some reason on August 31 those four stitches were cut, resulting in McFelin returning to hospital.
On September 19 the tube was reinserted and re-stitched.
It was replaced again days later.
In early October McFelin developed a cough and inflammation.
On October 7 he underwent a procedure to clean the tube area and reinsert the tube again.
Afterwards, McFelin continued to deteriorate and he died on October 14 from chest and abdominal sepsis.
After he died McFelin's family were "particularly concerned" about the cutting of his stitches at Elloughton Gardens.
"Their position is that the cutting of the stitches that day was an operative cause of Mr McFelin's death,' said Coroner Elliot in his decision released today.
"These matters occupied considerable attention at the inquest.
"Evidence was given by a number of witnesses, including expert evidence from general surgeons."
Coroner Elliot determined McFelin died of sepsis, complications relating to his feeding tube, cancer and its treatment, and "emphysema and frailty".
However, he could find no direct correlation between the cutting of the stitches and McFelin's death.
"The sutures were cut while Mr McFelin was a resident at Elloughton Gardens," he confirmed.
"There is insufficient evidence to make a finding about who cut them or why.
"There is no evidence that the attending nurses cut them.
"The cutting of the sutures did not contribute to Mr McFelin's death."
McFelin's family had asked Coroner Elliot to make recommendations including demanding Elloughton Gardens to "create and implement competent and thorough event recording and investigation practices designed to ensure that adverse events are recorded at the time they occur".
They also wanted him to recommend that the home "adequately supervises its residents so that the risk of adverse events such as improper interference with medical treatment cannot occur".
However, Coroner Elliot declined to make those recommendations - or any others.
"I have found that the cutting of the sutures did not contribute to Mr McFelin's death," he repeated.
"I therefore have no jurisdiction to make any recommendations arising from the way in which this matter was investigated.'
He said there was "no evidential basis to make recommendations for supervision"
He confirmed Elloughton Gardens had a policy in place for reporting adverse effects and that it was "regularly updated".
While he could not give McFelin's family what they had asked for through the Coronial process, he acknowledged their suffering.
"The deterioration in Mr McFelin's health must have been a sad and difficult time for him and his family," said Coroner Elliot.
"As Mrs McFelin said, when he became ill with laryngeal cancer, their lives changed overnight.
"Mr McFelin became less able to do the things he enjoyed doing, such as bowling."
He said the findings focused on McFelin's medical conditions and the care and treatment provided to him in the period before his death.
"However, as I close this inquiry, I am thinking of Mr and Mrs McFelin, of their time together, of their family, and of the words of (a doctor involved in the inquest) - 'I found their relationship a loving one, and filled with spiritual contentment and calmness, despite facing a serious illness.'"