A HOUSEBOUND woman suffering severe and chronic pain turned to nitrous oxide, laughing gas, to ease her suffering but died at home amid poor communication between different parts of the NHS.

An inquest heard that opportunities were missed to address her growing addiction to the gas.

Sarah Dudley, 46, had complex regional pain syndrome (CRPS ) and diabetes and was on high does of painkillers. But they were not enough and so she turned to nitrous oxide, an inquest heard.

In the days before her death she was taking increasingly high doses of the gas.

Consultant pathologist Adnan Al-Badri told the hearing the gas, which like nicotine is addictive, was not recorded in post-mortem tests because it is present in the atmosphere. Dr Al-Badri said it would have depressed her respiratory system and eventually caused death.

The inquest heard that in the weeks before her death carers at We Care Together Southampton had raised concerns about the nitrous oxide use and spoken to community nurses. But the GPs at Woolston Lodge Surgery were not told, the inquest heard.

Her son Iain Dudley was unhappy about the quality of treatment. He told the hearing that his mother had been refused 'ketamine infusion', which he said was an effective painkiller.

Mr Dudley said: "If mum had got the treatment she needed the whole thing wouldn't have happened. I feel it is medical negligence. I don't blame the NHS I blame the GPs at Woolston Lodge."

He said he tried to stop her use of nitrous oxide but she would order 100 canisters online and have the postman deliver them to her personally.

An NHS review into the death has called for changes in procedure and there has been an increase in nurses at community nursing teams.

A senior manager, Clare Schofield, undertook a review for Solent NHS Trust and reported there was a lack of documentation relating to Ms Dudley's care worsened by high workloads for staff. There was a lack of communication between the community team and the GPs which meant that Ms Dudley's rising use of nitrous oxide was not properly addressed.

Senior coroner Grahame Short asked: "There was a failure to recognise (Ms Dudley's) decline or of continuity, there were different nurses on different occasions? Ms Schofield agreed.

Suzi Graves, senior matron for community nursing in Southampton, said changes had been made: closer attention would be paid to diabetic's blood sugar levels, managers would keep a closer eye on patients with complex needs, and more nurses were being recruited. There would be better liaison between the different parts of the NHS.

Ms Dudley died overnight on February 14-15 and emergency services were called to her home in Sycamore Close, Bursledon. The police attended and said there were no suspicious circumstances.

Coroner Mr Short said Ms Dudley had inhaled an "excessive volume of nitrous oxide gas in an effort to control her pain". He recorded a conclusion of misadventure and not a drug-related death, as nitrous oxide is a gas and not a drug.

After the inquest Ms Dudley's brother, also called Iain Dudley, said: "She was a very kind person, she was running a support group for people with CPRS, a world wide thing. She was always doing something for other people."

The Daily Echo asked about the failings revealed by the inquest and in a statement, Dr Dan Meron, chief medical officer at Solent NHS Trust, said: “I would like to extend our sincerest condolences to the family and friends of Ms Dudley.

“The safety and well-being of the people who use our services is of the utmost importance. We continue to work with our partners to improve our processes and to ensure we provide consistently safe services.”