A mum-of-two died after doctors mistook her sepsis symptoms for muscle sprain and referred her to a GP instead of A&E, an inquest heard.
Shahida Begum, 39, visited Newham University Hospital in London after noticing a red rash and experiencing pain in her right side with sickness, dizziness and coughing.
The mum-of-two was diagnosed with a muscle sprain and given medication – but she died the following day from multiple organ failure after suffering three cardiac arrests.
The inquest concluded that if Ms Begum had been sent to A&E following her screening assessment "it is likely her death would have been avoided".
Mohammed Rahman, her husband of ten years, said the family has been "shocked and devastated" by her sudden death.
The family-of-four, from Ilford, London, were enjoying their first year in a new, refurbished home where they hoped to create "a lifetime of memories".
Speaking after the inquest, IT manager, Mr Rahman, 47, said: "Throughout the whole period that Shahida was ill, we had been in contact with a number of healthcare professionals, all of whom reassured us that it was not life threatening and that she would pull through.
"Even when she was admitted to A&E, I knew it was serious but I did not think we would lose her.
"It seemed to happen so suddenly and I did not have time to come to terms with what had happened.
"It is still difficult to think that my wife and the mother of my children would still be alive if her symptoms had been diagnosed sooner.
"We miss Shahida every day and it is heart-breaking to know that she is no longer with us and will not get to see her children [Maryam, six, and three-year-old Amaan] grow up.
"All we can hope for now is that lessons are learned and that measures are put in place to ensure that this does not happen to any other families.
"We wouldn't wish this pain on anyone else."
Ms Begum, a nursery nurse, was directed towards the GP service – run by Newham GP Co-operative – where Mr Rahman took her the following day.
What is sepsis?
Sepsis is the reaction to an infection when the body attacks its own organs and tissues, the UK Sepsis Trust says.
Also known as blood poisoning, it is a potentially deadly condition which can be easily treated if caught early enough.
Adults and children suffer different symptoms, however.
There is no one sign in particular, and the serious condition can initially look like flu, gastroenteritis or a chest infection.
Adults should seek medical help urgently if they develop any of the following:
- Slurred speech or confusion
- Extreme shivering or muscle pain
- Passing no urine (in a day)
- Severe breathlessness
- It feels like you're going to die
- Skin mottled or discoloured
If your child is unwell with a fever or a very low temperature, or has had a fever in the last 24 hours, parents should ask whether it could be sepsis.
Any child who is breathing very fast, has a "fit" or convulsion, looks mottled, bluish or pale, has a rash that does not fade when pressed, is very lethargic or difficult to wake, or feels abnormally cold to the touch might have sepsis.
Any child under five who is not feeding, is vomiting repeatedly, or hasn't had a wee or a wet nappy for 12 hours might have sepsis.
Her condition was deteriorating rapidly and she collapsed and was taken back to Newham University Hospital by ambulance and diagnosed with sepsis.
Senior coroner Nadia Persaud will issue a Prevention of Future Deaths order instructing Newham GP Co-operative and Barts Health NHS Trust, which runs the hospital, to tell her what steps they will take to improve the screening service which decides whether patients are referred to GPs or A&E.
An internal investigation by Barts Health NHS Trust also highlighted a range of issues.
A report found the "root causes" for Ms Begum's death was that she was incorrectly sent to the GP area, a diagnosis of a muscle sprain did not fit with all of her symptoms, sepsis was not considered and National Institute for Health and Care Excellence guidelines for assessing the risk of sepsis were not followed.
She returned home from work on July 3 last year complaining of feeling unwell.
Over the coming days her symptoms persisted and she developed a rash under her right arm.
She attended an out of hours GP appointment on July 6, but was reassured that her symptoms were nothing to be concerned about.
But her condition continued to deteriorate over the weekend and on July 9, Mr Rahman took her to hospital where – following an initial 'screening assessment' – she was directed to the GP service and prescribed pain killers.
She returned to the hospital on July 10 and she was diagnosed with sepsis.
Ms Begum was given antibiotics, fluid resuscitation and medication to boost her blood pressure while fluid was also identified on a CT scan.
A decision was made to drain the fluid but she died just after 6pm on July 10 during preparations for the procedure.
The report by Barts NHS Trust made 12 recommendations, including annual sepsis awareness training for all clinical staff working in the urgent care centre.
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