Staff at the Northern General Hospital sent a woman dying of liver failure to the wrong hospital in an ambulance.
Hayley Parsonage, aged 26, was being transferred from Sheffield to the specialist liver unit at St James’ University in Leeds for urgent treatment.
But her inquest heard a breakdown in communication between staff at the Northern General and the ambulance driver meant she was driven to Leeds General Infirmary instead.
Coroner Shibohan Kelly read evidence from Catherine Bailey, of Sheffield NHS Trust, who admitted staff had not clarified where to send Miss Parsonage.
“She left by ambulance and was taken to the LGI instead of St James’.
“The hospitals are a 10 minute drive from each other,” she said.
“The transfer team did not clarify with the driver which hospital to go to.”
Mrs Bailey added that while the delay had not impacted on Miss Parsonage’s chances of survival, the hospital’s ‘robust transfer system had been further strengthened’ since the incident.
The inquest also heard that Miss Parsonage, who suffered from sacral agenesis which affected her weight and height, was not weighed when she first arrived at the hospital in March 2012, just days before she died.
On that occasion nurses gave her intravenous paracetamol despite not knowing that someone of Miss Parsonage’s weight should have been given a reduced dose of the drug.
A pathologist later recorded the cause of death as liver failure due to a paracetamol overdose.
Dr Susan Croft, consultant of emergency medicine at the Northern General, said Miss Parsonage, from Sheffield, was not weighed.
“As a department there wasn’t the knowledge that someone of Hayley’s weight needed a reduced dose,” she said.
“We have 14 A&E consultants and nobody knew.”
The inquest continues.