Dr John Hubley's family called for a national inquiry into safety at the centres following the verdict.

His fiancee Prof Bren Neale said: "A catalogue of errors occurred in a system which failed to put safety first."

Dr Hubley, 58, died the day after suffering massive blood loss during surgery in January 2007.

West Yorkshire Deputy Coroner Paul Marks slammed Eccleshill Independent Sector Treatment Centre in Bradford, where the Leeds Metropolitan University principal lecturer was operated on, especially a system for obtaining blood in an emergency which he said was "globally flawed".

Blood desperately needed after Dr Hubley, from West Park in Leeds, suffered "torrential" bleeding in a rare complication of a keyhole operation to remove his gall bladder was delayed for over an hour.

The protocol for collecting blood - which involved a centre porter driving to nearby Bradford Royal Infirmary and back - was described as "Mickey Mouse" by the coroner.

Recording a verdict of misadventure aggravated by neglect, he said: "The system for obtaining blood was globally flawed and I have accepted the independent expert evidence that this represents a gross failure."

Urgent action had been taken on this, he said, but added he remained concerned that watchdog the Healthcare Commission inspected Eccleshill - which is run by Nations Healthcare - months before the tragedy and no concerns were raised.

The coroner also criticised the lack of a phone in the operating theatre, lack of specialist equipment was lacking and the fact no blood supplies were kept at the site. He said he would write to the Department of Health and the National Patient Safety Agency.

"Surgery is about safety, not what you can get away with," Mr Marks, sittting in Halifax, added.

Retired Leeds professor of surgery Prof Michael McMahon, the coroner's independent expert, earlier told the hearing Dr Hubley would probably have survived if the operation had been carried out at a fully-equipped hospital.

After the verdict, Dr Hubley's fiancee Prof Bren Neale said his family were considering further legal action over his death.

"John's children Alice and Kris and myself have waited 22 months for this inquest to take place and along with other member's of John's family and colleagues we remain deeply shocked and outraged at his untimely death," she said.

Prof Neale, a professor of life course and family research at the University of Leeds, added: "No one individual was responsible for John's death but there was a collective responsibility among those who commission, provide, carry out, support and monitor clinical and surgical procedures at this treatment centre," she said.

"We hope that some good can come out of John's death, particularly as he devoted his life to helping others."

She called for a national inquiry into patient safety and care at independent treatment centres, as well as a review of their use and how they work with NHS hospitals.

"Having to simultaneously register John's death and cancel our wedding and plans for our future together was unbearably painful, " she added.
Leeds North West Lib Dem MP Greg Mulholland also called for a public inquiry into the Eccleshill centre.

A spokeswoman for Nations Healthcare said everyone at the Eccleshill Treatment Centre deeply regretted the death of Dr Hubley and the centre had introduced measures to deal with complications like severe bleeding.
"We are committed to learning lessons from this rare event and we welcome the croner's confirmation that he is satisfied that these issues no longer exist at Eccleshill," she added.

A spokeswoman for Bradford and Airedale Teaching Primary Care Trust and Leeds Primary Care Trust said they would study the coroner's findings to ensure patient safety remained paramount.