Kingston Hospital has admitted a vital test result was not “considered” when it discharged a woman who died two days later of pneumonia, an inquest heard.

The blood tests of Pamela Bevans, 69, who had been living at Southborough Lodge before her death, were not all returned before she was sent home from hospital in September 2014.

Her husband, Victor Bevans, told West London Coroner’s Court today: “She was my soul mate, she was a good wife and mother.”

Hospital representative Ashley Irons said: “A test result was not considered and this lady was discharged without that information.”

Problems with lab machines led to a delay returning the results, which came in full just before 12.30am on September 26, hours after Mrs Bevan had been sent home. The results for various conditions, including inflammation for infection, were high.

On September 27 Mrs Bevans was rushed back to accident and emergency but, after multiple rounds of resuscitation, was pronounced dead.

The Surbiton resident suffered health problems including diabetes, breast cancer and lung and heart problems, but when she was first taken by ambulance to A&E on September 25, 2014, her symptoms were not thought to be linked to previous problems.

Doctor Laurence Sharifi, who took over the care of Mrs Bevan for the evening shift, said when he received partial blood test results back he went to the consultant to discuss how to proceed, but was told the patient would be discharged.

Senior coroner Chinyere Inyama said: “You didn’t ask her, ‘Have you seen the results?’”

Dr Sharifi said he did not, assuming she had seen the full results, adding it was a “regret”.

He said: “If I had seen them I would have, I feel that I would have, said something, something like, ‘Are you sure that you want to do that?’”

Consultant Dr Satwinder Palia said she did not recall Dr Sharif discussing the results with her but remembers being told by someone that the blood test results had come back, and that Mrs Bevans was going home.

She said she was not able to check the results herself as A&E was busier than usual.

Dr Palia added: “Now I will absolutely make sure that when I was reviewing patients I would review their results with them, I would take the time to do that. For my peace of mind to know that that patient was safe.”

Mr Inyama said in his conclusion: “The failure to review the blood tests contributed to the eventual outcome.”

Kingston Hospital has since created designated bays for ambulances bringing patients to A&E, updated its lab results system and introduced a colour label system to indicate that tests requested by A&E are more urgent.