A "remarkable and kind-hearted" woman died after doctors and nurses failed on 18 attempts in four hours to give treatment at Kingston Hospital.

58-year-old Kamalaloginidvi Pararajasingham, who ran Food Fare in Surbiton with her husband, died from sepsis last November.

Family members raised concerns at the inquest into her death yesterday, over the length of time it took doctors and nurses to start treatment.

No medication was given to Mrs Pararajasingham before she died because a string of medical staff could not insert a cannula in order to give intravenous drugs.

Doctors told West London Coroner’s Court that staffing levels and annual leave had put pressure on the department when Mrs Pararajasingham, of Selbourne Avenue, was admitted on November 18.

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Inquest: West London Coroner's Court

The inquest heard that for an emergency department of Kingston’s size, the Royal College of Emergency Medicine recommends 16 consultants booked to work in a standard week, but Kingston Hospital had just six on rota at the time.

Coroner Chinyere Inyama concluded that there were “missed opportunities” to “provide treatment that might have altered the outcome” as Mrs Pararajasingham’s condition deteriorated.

Two doctors from Kingston Hospital told the court it was a case which has led to an overhaul of protocol in dealing with sepsis patients.

Emily Ormerod, a consultant at Kingston Hospital who carried out a serious incident report following Mrs Pararajasingham’s death, told her family: “We completely and wholly accept we did not give your mother the best chance of survival.

“People were so bogged down in getting the line in, they forgot why they were doing it in the first place.”

Although the infection was noted as part of the initial assessment, Mrs Pararajasingham was not deemed a cause for concern and so the escalation through to consultant level was slow, the inquest heard.

READ MORE: Inquests into sepsis deaths

Mr Inyama said that a patient in Mrs Pararajasingham’s condition should be checked every hour, but that because of staff’s repeated attempts to insert a cannula, regular observations were interrupted.

Rachel Vivian, a consultant in emergency medicine, was leading a team looking after 70 patients that day.

She said: “Knowing what happened I wish I’d gone and seen her myself and put the line in.”

Mrs Pararajasingham’s daughter, Suji Sululsa Pararajasingham, who is also a doctor, told the court of her mother’s early life in Jaffna, Sri Lanka, and of her eventual move to the UK to settle in Surbiton.

She said: "Much like her name, which means lotus, she was unique.

"She remained honest and kind-hearted. She helped many people by sacrificing her own wealth and happiness.

"She was truly remarkable and kind-hearted person, she touched the lives of so many people during her 58 years.

"She always saw the good in people, she was unable to turn a blind eye when someone asked for help.

"Since mum's passing many people have come into the store truly saddened that she was not there to speak to. Mum had a profound impact on those in the community."

Workers determined soon after she arrived at accident and emergency that Mrs Pararajasingham had some kind of infection and needed intravenous fluids.

Staff nurse Amelia Harris told Mr Inyama a healthcare assistant undertook that task. He was unable to place a line before Mrs Pararajasingham was moved.

A nurse tasked with cannulation also failed, and about two hours later more attempts were made using ultrasound but these too were unsuccessful.

Dr Vivian then tried herself four times but was unable to place a line. A registrar was asked to place a central line, a longer tube which is placed in a larger vein, but before she had done so successfully Mrs Pararajasingham went into cardiac arrest.

The new protocol for staff to deal with sepsis within a set timeframe is due to come into force within the month.

Sita Soni, a solicitor in Boyes Turner’s medical negligence team said: "It is utterly tragic that a 58-year-old woman experienced a string of failures to provide her with basic care and medication.

"Mrs Pararajasingam’s family have been left devastated by her death, and whilst the inquest has provided some answers, there are still concerns about the care Mrs Pararajasingam received before she died.

"We hope that the investigation conducted by the hospital and the overhaul in the hospital’s sepsis protocol will lead to significant changes in the way patients with sepsis symptoms are treated to prevent similar tragic incidents in the future."

Jane Wilson, medical director of Kingston Hospital, said: "Our thoughts and sympathies are with Mrs Pararajasingham’s family and we are sincerely sorry for what happened. 

"We recognise, as the coroner has found, that we failed to provide Mrs Pararajasingham with the care that she needed. 

"We carried out a full investigation following Mrs Pararajasingham’s death and have made a number of changes directly related to the investigation. 

"Sadly in Mrs Pararajasingham’s case the team had difficulty achieving IV access in a timely manner to enable administration of fluids and antibiotics for the treatment of sepsis.

"The focus should have been on monitoring Mrs Pararajasingham’s condition and detecting her deteriorating condition.

“The trust has already learnt from the tragic death of Mrs Pararajasingham and is focusing on areas of clinical care where we need to improve our processes. 

"We will continue our work with our sepsis improvement team to implement national best practice to ensure that outcomes are improved for patients (adult and children) with this life threatening condition."