Neglect by medical staff at crisis-hit Barnsley Hospital contributed to a patient’s death, an inquest heard.
Coroner Julian Fox said grandmother Lorraine Hargreaves became ‘forgotten’ in the system and linked her death to a catalogue of errors.
The mum-of-two was admitted Barnsley Hospital complaining of sickness during chemotherapy for a survivable cancer.
Two junior doctors failed to treat her condition as an emergency and two nurses failed to carry out observations for nine hours, give her enough fluids or alert senior doctors.
Mrs Hargreaves, aged 64, died less than 24 hours after being admitted in December 2012, when icy weather left staff struggling to cope.
Assistant Sheffield coroner Mr Fox said: “It is clear Mrs Hargreaves did not receive the medical attention she required, in part because of the prevailing weather conditions but principally because her treatment was not escalated when her abnormal blood results were seen.
“In addition she was not provided with sufficient intravenous fluid to maintain her blood pressure.
“There is a direct link between these circumstances and Mrs Hargreaves’ sad death which was contributed to by neglect.”
Barnsley Hospital NHS Trust recently discovered a £7.5 million hole in its finances and a health watchdog criticised the way it is run.
Mrs Hargreaves, of Elsecar, near Barnsley was suffering from non-Hodgkins lymphoma which is survived by nearly half of patients who have chemotherapy.
She contracted neutropenic sepsis, a recognised side effect, in which the number of white blood cells to help the body fight infections are reduced.
It has just a ten per cent mortality rate.
A staff nurse thought Mrs Hargreaves was ‘very ill’ when she was transferred to the acute medical unit at 5.30pm on the ‘chaotic’ afternoon of December 14, 2012.
Two junior doctors Dr Ugo Ihekwaba and Dr Johannah Cook, looked at her blood results but failed to call a registrar.
Staff nurse Joanne Mason had nine patients to look after and felt ‘unable to cope’ but did not request help, the court heard.
Ward sister Kerry Barron took over from Nurse Mason and was under the impression Mrs Hargreaves had been seen by a doctor.
But Mrs Hargreaves was not seen by a doctor until 7am the next day.
Ms Barron claimed her workload was ‘unamanageable’ due to short-staffing and the weather.
The inquest heard Mrs Hargreaves should have been given up to four litres of fluid to increase her blood pressure - instead she was given a litre in 16 hours.
Head acute oncologist Dr Julian Humphrey said: “This was well below a proper standard of care.”
The betting shop worker suffered a cardiac arrest at 12.25pm and died some time before 2pm on December 15 from multiple organ failure.
Barnsley Hospital NHS Trust launched an investigation and disciplinary action was taken.
The junior doctors have received extra training and the coroner is writing to the trust Chief Executive to ask them to re-examine the part played by the nurses.
Recording a narrative verdict Mr Fox said: “Lorraine Hargreaves died from neutropenia sepsis which is a recognised complication of the treatment necessary for her cancer.
“Her condition was diagnosed but not treated sufficiently and neglect contributed to her death.”
Family solicitor Matthew Brown from Raleys said her relatives had asked for the doctors and nurses to be refered to the General Medical Council and the Nursing and Midwifery Council.
A Barensley Hospital NHS Foundation Trust spokesman said: “The Trust and those staff personally involved with the care of Lorraine Hargreaves deeply regret the circumstances in which she sadly passed away. “We offer our sincere condolences to the family for their loss.
“The events have been thoroughly investigated and lessons learnt as a result of this incident, by both the hospital management and individuals, and improvements made to the processes and care provided by the hospital.
“The Trust takes the coroner’s findings very seriously and will consider any further action that may be necessary.”