A disabled hospital patient died after a procedure to ensure she was properly hydrated was delayed because doctors were unavailable.
Laura Mering was due to have a tube inserted to provide her with fluids at St James’s Hospital around February 13 last year.
But, at her Leeds inquest yesterday, (Jan 10) coroner David Hinchliff said the procedure, carried out under anaesthetic, was “thwarted by the unavailability of anaesthetists”.
The 23-year-old was eventually given a central line a week later but by then, Mr Hinchliff said, it was too late.
She died after choking on her own vomit, as a result of low fluid and food intake, on February 20.
Mr Hinchliff said there would have been risks associated with putting in a central line, but that medics had decided it was the best course of action.
He added: “Despite the risks and complications of central line insertion, had this been done when intended during the previous week, the outcome may have been different.”
The inquest heard Miss Mering had been born with severe intestinal problems and was wheelchair-bound because of a lack of function in her legs.
She had a long history of mental health issues, which may have been exacerbated by sexual abuse she claimed she suffered at the hands of a secondary school teacher, and also suffered with an eating disorder.
Mr Hinchliff was told her behaviour was difficult to manage and she would often pull out feeding tubes and lines.
It was sometimes necessary to forcibly take action under the Mental Health Act to make sure she was properly fed and hydrated.
Miss Mering, who was being looked after at a nursing home in Seacroft, was admitted to hospital on February 3 after refusing fluids for several days.
Mr Hinchliff said her subsequent treatment was complicated by her refusal to co-operate.
But he said the initial failure to insert a central line was “a missed opportunity to address Laura’s serious nutritional problems”.
He recorded a narrative verdict.