A private healthcare firm and NHS doctors both "missed opportunities" to provide urgent treatment that could have saved the life of a woman who died at Croydon University Hospital, a coroner has said. 

Failings by Virgin Care and Croydon Health Service NHS may have contributed to the death of Madhumita Mandal, 30, who suffered multiple organ failure while waiting eight hours of surgery, an inquest heard today.

Mrs Mandal, of Paul Gardens, Croydon, died on September 11, 2013, four days after being admitted to hospital with a ruptured ovarian cyst.

Her devastated husband today said his "world came crumbling down" following the IT worker's death and called for changes to the triage system at the hospital's urgent care centre (UCC), where receptionists with no medical training judge whether patients need emergency care.

EARLIER: 'Not that sick': Woman who died of multiple organ failure deemed non-emergency by receptionist

Prabhanjan Behera took his wife to the UCC, run by Virgin Care, on the morning of September 7 after she spent the night vomiting. But she was not seen by a doctor for 75 minutes because the receptionist believe she "wasn't that sick". 

There were further delays at the hospital's emergency department as doctors clashed over the seriousness of her condition, while the on-duty registrar admitted he was "distracted" from his job by his wife arriving at the hospital to talk to him.

Mr Behera, 38, said: "Losing Maddie has changed my life completely – I feel like I’ve lost everything and my world came crumbling down.

"I feel that there were a number of occasions that if doctors had intervened and treated her sooner, she would still be with me today. Every second counts when you are in hospital and I feel that Maddie’s condition was not taken seriously."

The couple arrived at the urgent care centre at about 7.15am and were checked in by receptionist Triveni Dhavade, whose only UK qualification was in mortgage advice, about 10 minutes later.

But despite being the only patient waiting Mrs Mandal was not seen until 8.15am because the doctor and nurse on duty were unaware she was there.

The nurse immediately transferred her to accident and emergency, where a junior doctor Jessica Davies was "extremely concerned" by her condition and wanted to sent her to intensive care.

But Dr Davies, who had only worked in the emergency department only a month, was overruled by her registrar, Ademola Tokan-Lawal, who wrongly diagnosed Mrs Mandal with gastroenteritis.

Giving evidence to the inquest this morning, Dr Tokan-Lawal acknowledged "in hindsight" he should have been "seriously alarmed" by Mrs Mandal's symptoms.

He also admitted leaving Dr Davies unsupervised for an hour while he left the resuscitation department to speak to his wife, who was suffering stomach pains.

The seriousness of Mrs Mandal's condition was not fully realised until consultant doctor Mayank Agarwal arrived at nearly noon, the inquest heard.  

She underwent surgery to remove the cyst but her condition deteriorated and she died of multiple organ failure and sepsis four days later. 

Coroner Selena Lynch, recording a narrative conclusion this afternoon, told the court she could not be sure Mrs Mandal's life would have been saved by earlier treatment but that it would be "unacceptable and misleading" to discount failings in the hours before her death.

She said: "I don't think it would be correct to say this woman died of natural causes. There is a possibility that her death was contributed to by failings in care and her death was preventable."

"There were several cumulative delays in the urgent care centre and emergency department in assessment and treating her.

"There were missed opportunities to take urgent steps that may have prevented Mrs Mandal's death but the evidence does not tell us whether her death would have been prevented by earlier appropriate assessment or treatment."

Dr Kathryn Channing, lead consultant at Croydon University Hospital's emergency department, said: "We would again like to offer our deepest condolences, and we have personally apologised to Mrs Mandal’s family.

"We are constantly checking and re-checking how we work, and since these tragic events two years ago, we have put in new measures to improve our care.

"We now have senior consultants on-site in the emergency department from 8am to midnight, when previously it was only six hours a day. We also have more doctors working every day, including in the evenings and weekends.

"Most recently, the trust has started a major campaign within the hospital to raise awareness of sepsis, and all of our doctors now carry pocket cards to help diagnose the condition more quickly."

Louise Forsyth, an medical negligence lawyer at Irwin Mitchell, which represented Mr Behera at the inquest, said: "Maddie was in a critical condition when she was taken to A&E at Croydon University Hospital and despite Prabhanjan repeatedly raising his concerns to staff about her condition and her medical history; she was not treated as a priority and instead faced a lengthy delay as her condition rapidly declined.

"When she was seen by doctors scans revealed internal bleeding but it was too late to save her life.

"We understand the NHS Trust is unhappy with the fact that non-medical staff are making decisions on the priorities and timings for the A&E walk-up patients and it is disappointing to hear of issues with commissioning groups such as this as this was a problem highlighted in the Francis Report following the Mid-Staffs public inquiry in 2013."

Both Virgin Care and Croydon Clinical Commissioning Group, which commissions the urgent care service, have been approached for a comment.