The devastated husband of a mother-of-two who died after her symptoms of sepsis were mistaken for a muscle sprain has called for lessons to be learned from her death.
Shahida Begum, 39, died at Newham University Hospital in east London on July 10 last year, just a day after complaining of a red rash, pain in her side, sickness, dizziness and coughing.
At an earlier screening assessment, Mrs Begum had been directed to the GP service at the hospital, run by Newham GP Co-operative, where she was diagnosed with muscle sprain and discharged with medication.
A coroner concluded that if Mrs Begum, from Plaistow, east London, had been sent to A&E following the initial screening "it is likely her death would have been avoided".
An internal investigation by Barts Health NHS Trust, which runs the hospital, found the "root causes" of Mrs Begum's death included a misdiagnosis of muscle sprain and a failure to follow sepsis assessment guidelines.
Her husband, Mohammed Rahman, 47, an IT manager, is now warning of the dangers of sepsis and calling for lessons to be learned.
He said: "As a family we have been shocked and devastated by Shahida's sudden death.
"Prior to the events that unfolded, she was a healthy and active person with no significant past medical history."
Mr Rahman said his wife had been "really happy" and looking forward to welcoming friends and family to their recently refurbished home.
The pair married in 2009 and had two children, Maryam, aged six, and three-year-old Amaan.
Mr Rahman said that, throughout her illness, healthcare professionals had reassured them that Mrs Begum's condition was not life- threatening and she would pull through.
"Even when she was admitted to A&E, I knew it was serious but I did not think we would lose her," Mr Rahman said.
"It seemed to happen so suddenly and I did not have time to come to terms with what had happened.
"It is still difficult to think that my wife and the mother of my children would still be alive if her symptoms had been diagnosed sooner.
"We miss Shahida every day and it is heartbreaking to know that she is no longer with us and will not get to see her children grow up.
"All we can hope for now is that lessons are learned and that measures are put in place to ensure that this does not happen to any other families. "We wouldn't wish this pain on anyone else."
Mrs Begum, a nursery nurse, returned home from work on July 3 last year complaining of feeling unwell.
After her symptoms persisted and a rash developed under her right arm, she went to an out-of-hours GP but was told it was nothing to be concerned about.
Her condition deteriorated and Mr Rahman took her to the hospital on July 9, where the screening decision, made by the GP co-operative group, led to a prescription of painkillers.
But the next day she collapsed in her GP surgery and was taken by ambulance to hospital, where she was found to have sepsis.
She suffered three cardiac arrests and died from multiple organ failure later that day.
Following an inquest at Walthamstow Coroner's Court, senior coroner Nadia Persaud concluded that "on the balance of probabilities" Mrs Begum would have survived if she had been directed to A&E on July 9 2018.
She said the mother-of-two's symptoms "should have triggered further clinical observation and investigation".
The coroner is to prepare a prevention of future deaths report asking Newham GP Co-operative and Barts Health NHS Trust how they will work together to make improvements.
The trust's internal investigation into Mrs Begum's death found the muscle sprain diagnosis did not fit with all her symptoms, sepsis was not considered. and the National Institute for Health and Care Excellence (Nice) guidelines for assessing the risk of sepsis were not followed.
Its report laid out 12 recommendations, including annual sepsis awareness training for all clinical staff working in the urgent care centre, and sepsis screening guidelines to also be made available.
A leaflet for patients at risk of developing the infection on discharge is to be developed and "key learning points" shared with all staff working in the GP area and emergency department.
A Barts Health NHS Trust spokeswoman said: "The safety of our patients is of the utmost importance to us.
"We will work with our partners in the GP Co-operative Newham to learn from this sad event, including raising awareness of how to spot the signs of sepsis.
"Our thoughts are with Mrs Begum's loved ones."
Alexandra Winch, specialist medical negligence lawyer at Irwin Mitchell who is representing the family, said: "While nothing can make up for Shahida's death, we recognise the recommendations that the hospital trust has included in its report.
"It is now vital that these are implemented so staff across all departments are aware of the signs of sepsis and how early detection is key to beating it."
A spokesman for Newham GP co-operative said: "The safety and dignity of our patients is central to our work.
"The death from sepsis of one of our patients is a tragedy and our thoughts are with the family of the deceased.
"We have learned lessons from this sad event."
The spokesman said all clinical staff have sepsis training and each consulting room has a sepsis score chart on permanent display.
He said the Newham GP co-operative clinical director was meeting the medical director of Barts Health NHS Trust and the senior consultant in the emergency department at Newham University Hospital to put the coroner's recommendations in place.