A mother of four children died after speaking to three separate health professionals who did not diagnose her correctly.
Alison Christian, 36, from Sheffield visited The Northern General Hospital when she felt pains in her abdomen. She was examined and wrongly diagnosed as having a chest infection.
After her symptoms gradually got worse, she revisited the hospital and was seen by a junior doctor, who had only been practising for 5 weeks, who didn't perform a physical examination and sent her home without any further investigation into her illness.
Mrs Christian was left in a considerable amount of pain and couldn't move. Mr Christian rang the health line Primecare, where a trained nurse was operating from home. The nurse told Mr Christian that she could not diagnose his wife unless she spoke to her over the phone. Mr Christian then had to carry his wife to the phone so that she could tell the nurse her symptoms.
After the nurse was informed of Mrs Christian's symptoms, she told her it was constipation and she should take some laxatives. Mrs Christian died the following day of a ruptured ulcer.
Ben Gent, the family's solicitor from law firm Irwin Mitchell believes a lesson can be learned through this. He said: There was obviously a mistake in the way that medical software was being used. The nurse was typing in information which was leading her to the wrong answers and the missed diagnosis. It is important that the person talking to the patient should respond to the patient's symptoms and needs, and not rely wholly on what they see in front of them on the computer screen.
"Regarding the junior doctor in A&E, the implication is that detailed supervision was necessary. The junior doctor should not have left Mrs Christian with unexplained symptoms and should have examined her thoroughly. I believe if these basic principles had been followed then Mrs Christian would still be alive today.
Following the inquest finding of death by natural causes contributed to by gross negligence on the part of the NHS A&E and Primecare service, Ben Gent said: The inquest has been distressing for the whole family but they feel that it has been conducted with the level of detail and sensitivity that Alison deserved.
"The coroner has been critical. In this case, that criticism is deserved.
"One effect of the inquest is to bring back to the family again what a terrible loss they have suffered and they now intend to take some time to come to terms with the entire process."