Bradford Coroner’s Court also heard claims routine observations of Laura Garner’s vital signs were not properly carried out, while resuscitation equipment was missing when doctors made desperate efforts to revive her.
The series of failures came in the 24 hours after the 18-year-old, of Baildon, was admitted to Bradford Royal Infirmary with back and abdominal pains.
Doctors ruled out appendicitis the next day but her condition suddenly worsened and she died from septicaemia due to a serious bacterial kidney infection in a case her consultant described as “exceptionally rare”.
Abid Hassan Mohammed Salih, who was then a registrar, said he recommended giving her an antibiotic when he admitted her on September 22 2009 but did not prescribe it and it was not given to her. He prescribed a second antibiotic to her the following evening for a urinary tract infection but it was never administered.
He told the hearing hospital procedures had now changed and he would write a prescription rather than leave it for junior doctors.
Consultant surgeon John Griffith, who was in charge of Laura’s care, said he had “never seen a case progress like Laura”. Her body had mounted only a partial response to the infection which was “very unusual, very tragic and very upsetting for everyone”.
He had not thought she had the serious kidney complaint based on test results and examination. On the evening she died, he was called to see another case before reviewing her in person although he had seen a patient nearby.
“When I saw her sat up in the next door bed I did not appreciate she was as ill as she was,” he said.
Ward manager Angela Hurtault said it would have been normal to carry out observations every four hours. If abnormalities were detected these would have been stepped up but this had not happened.
Laura’s mother Anne gave harrowing details of the moment she learned her daughter had died in a telephone call from staff. She had earlier been very worried about her daughter, who complained of being very hot. “She was laid in bed propped up and you could see her heartbeat in her neck and her chest,” she said.
The inquest continues.