An inquest at West London Coroner’s Court found that there were “missed opportunities” which may have prevented Mrs Kamalalginidevi Pararajasingam’s death from sepsis.Mrs Pararajasingam, who ran a convenience store in Surbiton, died from sepsis at Kingston Hospital on 18 November 2015. She went to the hospital early on 18 November with a fever, pain on passing urine and general confusion. Medical staff recognised that Mrs Pararajasingam was suffering with an infection and required intravenous antibiotics. These were not received before she died as medical staff were unable to insert the cannula to administer the medication.Coroner, Chinyere Inyama heard that doctors and nurses failed on 18 attempts in four hours to provide treatment at Kingston Hospital. Eventually a registrar was asked to place a central line but before this was done, Mrs Pararajasingam went into cardiac arrest and died. The post mortem found that the main cause of death was septic shock.Mr Inyama said that as a result of Mrs Pararajasingam’s condition, she should have been monitored every hour, but this was not done. He also said that there were “missed opportunities” to “provide treatment that might have altered the outcome.”Dr Emily Ormerod, a consultant who carried out the internal investigation at the hospital following Mrs Pararajasingam’s death, told her family – “We completely and wholly accept we did not give your mother the best chance of survival.”The West London Coroner’s Court was told that the hospital’s protocol in dealing with patients with sepsis has been amended but it has not yet been implemented.Mrs Pararajasingam’s daughter said:"It is clear that staff had tunnel-vision in their attempts to insert a cannula and failed to see that our mother was deteriorating. We are truly saddened that despite sepsis awareness campaigns and the hospital’s own guidelines, our mother did not receive the treatment she needed.We are truly devastated by the loss of a kind hearted, honest and loving mother. Mum was truly unique, she always saw the good in people and could never turn a blind eye to someone who needed her help. She had a profound effect on many people especially to those visited her shop. We’d like to thank our friends and the community for their kind words and support through this difficult time.We hope that Kingston Hospital and many other emergency departments across the country take lessons from our mother’s death and implement change, so that this doesn’t happen to other patients.“The family is now considering legal action against the Trust. Law firm Boyes Turner is representing the family. 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.”
