William Convery, 67, who was recovering from a heart operation and was complaining of stomach pains, should have been admitted to hospital, discharged or transferred within four hours of arriving at Aberdeen Royal Infirmary's emergency department at 9.20am on November 19, 2012, according to Scottish Government targets.
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Howver, despite doctors quickly deciding he needed to be sent to an acute medical assessment unit, he remained in A&E until after 8pm. He spent much of that time on a trolley, due to a large number of patients requiring treatment. Mr Convery, also know as Ian, then faced further delays in seeing a doctor.
His condition deteriorated at 6am the following morning and he passed away at noon, after being transferred to the high-dependency unit, with bowel and heart conditions given as the cause of death.
Despite receiving an apology from NHS Grampian bosses, his widow Sandra Convery took her case to the Scottish Public Services Ombudsman, which yesterday upheld three separate complaints.
The health board was criticised for levels of care offered to the patient, and for not alerting Mrs Convery soon enough of her husband's worsening condition. By the time she travelled to the hospital from her home 35 miles away in Turriff he had passed away.
Mrs Convery, also 67, was then treated with a "fundamental lack of sensitivity", the Ombudsman said, after she was asked to sign her husband's death certificate before seeing his body. When she did see her husband, it "looked as if he had died in extreme pain".
She said: "The treatment he got in his final hours was horrendous and I lost my partner in life. I've barely stopped crying since it happened. He was screaming when he died - it was etched on his face when I saw him. I look at my photos of Ian and I can't see him. I see that body lying on the bed.
"If they had treated him properly that morning there's still a chance he would be here today."
Mr Convery worked as a gardener until his death and also acted as a carer for his wife, who has emphysema. Since his death, she has been forced to rely on professional care workers.
A spokesman for NHS Grampian, referring to Mr and Mrs Convery as Mr and Mrs C as they had been called in the Ombudsman report, said: "On this occasion we fell well short of the standards of care and compassion we aspire to. We regret the care offered to Mr C was inadequate and that our actions caused additional distress for him, for Mrs C and for their family.
"Mr Carey, chief executive, wrote to Mrs C on March 13 last year and, with senior clinicians from the emergency department, met her on March 25 to discuss the investigation carried out by NHS Grampian. However, we will be writing again to Mrs C to offer an unreserved apology for the distress caused.
"All of the recommendations will be acted on as part of an action plan that will be shared with the Ombudsman. We are absolutely committed to learning lessons from this tragic incident."