A bride-to-be died after doctors refused her a crucial CT scan despite her being found screaming in pain on a hospital floor.
Care worker Tessa Harker, 21, was making plans to tie the knot with fiance Rob Powley but suffered a perforated stomach ulcer in March last year.
An inquest heard she was first sent home from the Cumberland Infirmary in Carlisle after being told her pain was merely a stomach bug.
Later, while in a hospital cubicle she was found screaming in pain on the floor - yet still her family's calls for a CT scan were denied.
By the time the deadly 7cm hole was detected, her ulcer had burst. She underwent surgery but died the next morning - six days after her first A&E visit.
Dr Julian Thompson, an anaesthetics consultant at North Bristol NHS Trust, said had she had her scan earlier the ulcer may have been found.
Now Cumbrian Coroner Dr Nicholas Shaw has recorded a verdict of 'death by natural causes' but crucially added 'exacerbated by delays in treatment'.
He said: 'I feel that more should have been done to establish a diagnosis.
'I am of the opinion that had Tessa been involved in an attempt to find a firm diagnosis then she would have had a better chance of coming through this than she did.
'I personally feel a more vigorous investigation should have been undertaken.'
After the inquest in Cockermouth, North Cumbria University Hospitals NHS Trust said lessons had since been learned from the tragedy.
Their damning internal review found clear warning signs that Miss Harker's condition was deteriorating were missed.
After the inquest, trust chief executive Stephen Eames said: 'I wish to extend my sincere apologies and deepest sympathy to the family of Tessa Harker..
'It has been recognised that the care provided to Tessa fell short of what we would expect.
'Lessons have been learned and a number of actions have been put in place that we believe will further improve patient safety.'
Her fiance, Mr Powley, told the inquest how she spent her final few days in agony, having initially been told it was a bug and sent home from hospital twice.
He said that they repeatedly asked for tests to find out what was wrong, but were accused of overreacting by hospital staff.
The care home worker, who lived with her fiance, died at the city hospital on March 6th last year, six days after she first took ill.
Mr Powley said she occasionally suffered from stomach pains but had previously battled with eating disorders and they thought it was linked to that.
But she first fell seriously ill on Wednesday, March 1 2016, when she was sent home from work with stomach pains.
Mr Powley said she was seen by both A&E and Cumbria Health on Call (CHOC) staff at the infirmary later that day.
She was told it could be a bug and sent home. However, he said she later started vomiting and was up all night with the pain.
The next day they called her local GP, in her home town of Wigton, Cumbria, who agreed it could be a bug, but admitted her to hospital for tests and monitoring.
Mr Powley drove her to A&E and waited with her, describing how she was doubled over in pain and being sick.
She was admitted to a ward overnight, but was again sent home the next morning with anti-sickness medication.
By that evening she was again in extreme pain, so Mr Powley and her mother Valerie took the decision to phone for an ambulance.
As it took so long in the end they drove her in - only for staff to mistake her pain for gastroenteritis.
At midnight she was transferred to a different ward and and the duty registrar said they would carry out a CT scan the following day.
However, the next day - March 4 - he rang the ward, only to be told for some unknown reason there would be no scan after all.
Mr Powley, and Miss Harker's mother visited her a few hours later only to find her in a single-bed cubicle covered in vomit.
He said: 'She was on all fours on the floor, screaming in pain. We sat and watched her in agony.
'She was left half naked in the top she was wearing when she came in. There was no care at all.'
Mr Powley said her stomach was swelling so they went to speak to her consultant, Frank Hinson, and asked why she hadn't had a CT scan.
However the inquest heard the consultant told them he had been a doctor for 20 years, and did not want to expose a young woman to radiation unnecessarily.
Mr Powley added: 'At this point we were becoming incredibly frustrated. He said we were making her out to be more poorly than she was and accused us of overreacting.'
The grieving fiance told how the family spent all day at her bedside only to see Miss Harker become increasingly distressed.
He hearing was told he rang at 10am the next day - March 5 - only to be told there was no change.
But an hour later Mr Powley received a call saying she'd taken a turn for the worse, with staff finding her unresponsive in bed.
Miss Harker was resuscitated and transferred to the Intensive Care Unit and finally had a CT scan, which showed she had a ruptured stomach ulcer.
She underwent surgery but the infection had spread and when Mr Powley saw her at 6.30am on March 6, he admitted: 'I told myself I was going to lose her.'
Miss Harker's heart stopped later that day and efforts to save her failed. Mr Powley claims the impression he got from hospital staff was that if the ulcer had been diagnosed earlier, they could have done more.
Shaker Alseifi, the registrar who initially advised a CT scan, said this was later overruled by Mr Hinson.
Mr Alseifi said he had felt that further investigations were needed, via a scan, but it was 'not uncommon for a more senior consultant to have a different opinion.'
Coroner Dr Shaw asked the consultant: 'Mr Alseifi recommended a CT scan. Why did you did not request a scan?'
But Mr Hinson said although a scan had been recommended, it did not mean one must be carried out.
He said: 'When a consultant comes onto the ward then we start the assessment off from scratch.'
Mr Hinson was asked why he had not checked Miss Harker's National Early Warning Score (NEWS), which is used to monitor any changes in a patient's condition.
He said: 'I don't know. I can't answer that.'
Credit: Daily Mail