A CORONER has delivered a narrative verdict at the inquest of a Neath dental nurse in which he criticised the ambulance crew who attended her home hours before her death.
Sarah Thomas, 30, who battled with the after-effects of a brain tumour which left her without two-thirds of her vision, died on May 5, 2007.
Coroner Philip Rogers said that after considering all the evidence heard over five days it had been a "very difficult case to decide". He said this was due to the differing accounts heard from Miss Thomas's parents Kenneth and Madeline, and the paramedics.
Mr Rogers said: "Both Mr and Mrs Thomas and the ambulance crew maintained their version of events despite extensive questions by myself and counsel from the interested persons."
Mr Rogers said he had found there had been failings.
He said: "My findings are that there were serious failings in the way in which the crew went about their assessment and recording her condition that night."
But given the crew's lack of knowledge and the rarity of Miss Thomas's condition, he said: "This failure cannot be labelled as gross failings."
In his detailed narrative verdict, which was around three A4 pages long, he said that Miss Thomas had suffered a complete failure of her pituitary gland, meaning she was required to take hydrocortisone daily.
He said that on the day before her death she developed symptoms of gastroenteritis and her GP prescribed her with antibiotics and an antiemetic (a drug to combat nausea).
He said later she called for an ambulance complaining of a stomach bug and could not control her breathing.
"Sarah was not taken to hospital and the crew left the house at 1.50am having had a discharge of treatment form signed by Sarah's mother at 1.30am," he said.
He said she was last known to be alive at 3.45am but was found dead by her father in the bathroom at 9am.
Mr Rogers said: "The paramedic crew carried out a primary survey but there were serious failings in that which they carried out."
These included, he said, an inappropriate method used to assess respiratory rate, no further recording of respiratory rate, no attempt to listen to Miss Thomas's chest with a stethoscope, no assessment of her abdomen, no attempt to repeat observations, the blood pressure is likely to have been inaccurate, and there was a failure to get details of the long-term medication Miss Thomas was taking.
Mr Rogers added that Sarah's parents had no knowledge of Addisonian crisis at that time and the condition did not seem part of paramedic training and the crew had no previous knowledge of the condition.
Mr Rogers said that due to the failure to carry out an appropriate assessment "it was not possible for Sarah to make an informed decision" on whether to go to hospital or not.
He continued: "By accepting Sarah's mother's signature the crew failed to ensure that Sarah fully understood the possible consequences of not going to hospital. If Sarah had been taken to hospital it was likely she would have received intravenous hydrocortisone and fluids and her death would not have occurred on May 5 in 2007."
Mr Rogers said he would record the medical cause of her death as 1a circulatory collapse as a result of gastroenteritis, with part two, panhypopituitarism and adrenal insufficiency.
A Welsh Ambulance Service spokesperson said: "The Trust will be giving full and urgent consideration to the coroner's narrative verdict to ensure that all opportunities are taken to continuously improve our service."