Daughter of a former England cricketer died from sepsis, pneumonia and Chron's disease after paramedics failed to alert doctors to her symptoms
Bethan James, 21, daughter of ex-England and Glamorgan batsman Steve James had visited hospital multiple times in the days leading up to her death - but she continued to be ill when released home.
Paramedics were called to her house when she deteriorated at home - but a coroner found delays in her treatment and a lack of urgency.
By the time she was seen at hospital Bethan was gravely ill and died with sepsis within hours of being admitted to the emergency department.
Her sports journalist father had been covering the Six Nations rugby match between Wales and Ireland in Dublin when his daughter was taken seriously ill.
But due to weather delays was unable to get home and see her before she died.
The inquest heard ambulance staff attending Bethan's home had not requested emergency backup, struggled to insert an IV line, and did not issue a pre-alert to the hospital to warn them of her serious condition before she was admitted.
On arrival to University Hospital Wales, Cardiff, Bethan was admitted to the less serious 'majors' unit rather than to resus where medics held a 'cognitive bias' to more immediate treatment.
The hearing was told that a lactate reading obtained an hour after her arrival eventually prompted more senior doctors to become involved in her care.
Senior Coroner Patricia Morgan said: 'I find that if earlier recognition and prompt action in response to Bethan's condition by ambulance services had occurred this would have resulted in a pre-alert to the emergency department.
'This would, and ought to have, resulted in direct admission to resus with clinical staff waiting for her.'
She added: 'Earlier treatment would and ought to have commenced' and that 'the involvement of other specialists would and ought to have occurred at an earlier stage.'
'Cognitive bias towards resus patients, as described by Dr Thomas, would have been directed in Bethan's favour from the time of her arrival rather than once the lactate result was available.
'On balance, I find that had this direct admission to resus and prompt recognition and treatment occurred, then cardiac arrest would not have occurred when it did, which would have enabled more time for other specialities to become involved in Bethan's care.
'On balance I find that Bethan would not have died.'
A post-mortem examination found Bethan died from a combination of sepsis, pneumonia and Crohn's disease.
Bethan had been diagnosed with Crohn's in the previous months and had been admitted to hospital on a number of occasions in the days leading up to her death but sepsis was never diagnosed.
During the hearing, her mother Jane James the court she felt medical staff missed opportunities to treat journalism student Bethan for sepsis and had been 'dismissive' of her condition.
She said: 'It's heartbreaking as a mum to know that her life could have been saved.'
Mrs James described Bethan as a 'caring and beautiful' beautiful person who would have made a 'brilliant' journalist.
Giving a narrative conclusion the coroner said Bethan had attended hospital 'multiple occasions' between 27/1/2020 and 6/2/2020 but was repeatedly sent home.
Ms Morgan said: 'Bethan was reluctant to return hospital due to her lack of confidence arising from earlier attendances at hospital.'
When her condition deteriorated on February 8, 2020 her mother Jane dialled 999 and a rapid responder arrived at her home.
Ms Morgan said: 'The rapid responder identified Bethan was in need of admission to hospital and request a back up ambulance at a non-urgent grade of P3, Bethan's condition warranted an emergency response.
'There was no pre-alert issued to hospital to make them aware of the seriousness of her condition.
'Bethan was transferred to the UHW majors area of the department when she should admitted directly to resus.
'There was an extended transfer between ambulance and hospital and a delay in recognising Bethan's critical condition once she was admitted.
'This delayed the escalation of her treatment and the input of specialty doctors into her care.
'Bethan sadly went into cardiac arrest and died.'
Following the ruling Ms Morgan offered her condolences to Bethan's parents who had sat through the hearing.
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