A woman's life could have been saved on two occasions but for a "gross failure to provide basic medical attention" by hospital staff and an out-of-hours primary care service, an inquest has found.
Alison Christian, 36, died two days before Christmas 2005 at the Northern General Hospital in Sheffield after accident and emergency staff and a triage nurse from the telephone service Primecare failed to spot her symptoms.
She was suffering from a peritonitis, an inflammation of the membrane surrounding the abdominal organs, and a perforated duodenal ulcer.
Ms Christian, who was fit and healthy before she fell ill, could have been operated on if her condition had been recognised. But it was not diagnosed "until she was beyond help", an inquest at the Bio-Medical Legal Centre in Sheffield heard.
Her family's solicitor called for lessons to be learned after the inquest, at which Christopher Dorries, Coroner for South Yorkshire West, said: "There is a direct causal connection with the death in that (on the balance of probabilities) Ms Christian would have survived had her condition been acted upon."
Ms Christian collapsed at her home in Danewood Avenue, Sheffield, on December 19. A "full and proper" examination was carried out at the hospital which reached the "entirely reasonable diagnosis" of a chest infection, he said.
She returned to the accident and emergency department the next day complaining of significant abdominal pain, a raised heart rate, and shallow breathing, the inquest heard. Although she showed symptoms "that cannot be ignored" her abdomen was not examined and her blood pressure was not taken.
Mr Dorries said: "It was agreed that an examination of the abdomen would more likely than not have shown signs warranting further investigation such as tenderness or perhaps rigidity. This would (on the balance of probabilities) have led to a diagnosis of the problem at a time when Ms Christian's life would have been saved."
The failure to "do that which plainly should have been done, thus leading to the failure to diagnose" was a "total and complete failure", he said.
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Recording his verdict, he said: "The conclusion as to the death is that Alison Christian died from natural causes contributed to by neglect."
