AN 80-YEAR-OLD woman who died of a chest infection was not classed as an emergency case by a hospital even in the hours leading up to her death, an inquest heard.
Following a two-day stay at the Royal South Hants Hospital for rehabilitation she was transferred back to Southampton General Hospital where she died on August 15, 2010.
But the Southampton inquest heard on her arrival she was not treated by a doctor.
Southampton coroner Keith Wiseman said it would be difficult to fault the frequency of observations on Mrs Murray at the Royal South Hants Hospital and that staff numbers were up at the time.
Delivering today's narrative verdict, Mr Wiseman pointed to periods of time in Mrs Murray's care, notably her monitoring by nurses at the Royal South Hants Hospital, the time spent waiting for an out of hours doctor to attend her rather than sending her back to Southampton General Hospital and her time spent after being admitted to the General Hospital.
He said: “At no time from the morning of August 14 onwards at either the Royal South Hants Hospital and the General Hospital on her return, was Mrs Murray treated as an emergency or even indeed as someone requiring antibiotics and certainly not as someone about to die.”
He added: “She had again been admitted [to Southampton General Hospital] as an emergency but almost on a precautionary basis.
“What that sadly led to was that she was not actively seen by a doctor at any time before she was found almost certainly having already passed away.”
Although he said the suggestion that, had she been seen in that time, only one dose of antibiotics could have been administered which would have been unlikely to have a significant effect, would not be particularly reassuring to the family.
The inquest has previously heard how staff at both hospitals said they were happy with their treatment of Mrs Murray and said there was nothing to suggest her condition would deteriorate so suddenly.
It has also heard that both hospitals also conducted reviews of her care but no specific problems were found.
Mrs Murray's son Stephen said the family were pleased with the verdict and did not rule out taking legal action against the hospitals in future.
Judy Hillier, Director of Nursing and Quality at the Solent NHS Trust, representing the Royal South Hants Hospital, said: "We are very sorry a life was lost.
“We will be looking in detail at the Coroner's findings to establish how we can make further improvements to our services.
“It is our aim to consistently provide the very best care possible for anyone who uses our services.
“We will always work hard to understand what went wrong or where we can improve when we fall short of expectations."
Gail Byrne, director of quality at University Hospital Southampton, for Southampton General Hospital, said: “We send Mrs Murray's family our sincere condolences for their sad loss and will continue to work with them to address any remaining concerns or questions they have.
“While this was a difficult case which involved a vulnerable patient whose condition deteriorated very suddenly, there is much learning for us as an organisation and as individuals as a result and we will ensure her family are kept fully informed of the actions taken.”