A former teacher's death was "hastened" after the oxygen tube to his mask became disconnected while he was in hospital, an inquest has heard.
James Johnson, 83, went into Wrexham Maelor Hospital with Covid pneumonia on 3 January 2021 and was one of eight patients within three bays.
On 13 January, a doctor went to check on him and found him dead in his bed.
An investigation did not determine how the tube was disconnected and a coroner recorded a narrative conclusion.
At the time of his death from Covid pneumonia, Mr Johnson, of Ffordd Elfed in Wrexham, was declining and palliative care had already been discussed.
He was being cared for by two members of staff, the only two who had been tested to enter the room where he was being cared for as a result of staff pressures during the pandemic.
The usual ratio is one nurse to two patients.
The inquest heard when Mr Johnson was checked on by a doctor in the early afternoon, he had died and the doctor noticed his oxygen mask was not connected to the supply.
A subsequent investigation could not establish how this happened, though it was speculated it could have been leaned on by Mr Johnson when he moved in bed, but there was no evidence to support this.
A medical engineer who examined the equipment thought the force required to pull the tube out deliberately would not have been possible, considering how ill he was.
As a result of this, Betsi Cadwaladr health board has introduced a tag system so there is always one member of staff in the room with patients such as Mr Johnson, to ensure they are monitored.
Coroner for North Wales, East and Central, John Gittins, said that at the time of Mr Johnson's death "this was an organisation working under enormous pressure" and staff were "doing the best they could".
"In no way does that detract from the awfulness of what happened," he added, and acknowledged that what happened had hastened Mr Johnson's death.
Mr Johnson, who was an art teacher and deputy head at the former Groves School in Wrexham before running a building firm, had been shielding for much of pandemic due to health problems including diverticulitis.
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