An undetected brain injury caused a Worksop woman to develop a form of pneumonia which caused her death.
Christina Blow, who was known as Tina, died aged 47 at Bassetlaw Hospital on 20th April 2013 after developing Bronchopneumonia.
At the inquest, conducted by Nottingham Deputy Coroner Heidi Connor, it was heard how Tina first went to see her GP in December 2012 after becoming confused and losing her mobility.
Tina was referred to a consultant at Bassetlaw Hospital in January 2013.
However when she was referred for an MRI scan there was a delay in getting an appointment date set.
Miss Connor said: “There has been a breakdown in the interpretation of the word urgent and it has been explained that it was custom and practice for consultants requesting MRI scans which were required within four weeks to be discussed with the consultant radiologists.”
The consultant who referred Tina was not aware of this policy and the process was not written down officially until December 2013.
In March 2013 Tina was admitted to hospital and a brain abscess was detected during a CT scan.
Miss Connor said: “The abscess resulted in a brain injury which effected her breathing, swallowing and mobility and this made her susceptible to respiratory infections.”
Miss Connor concluded that Tina developed a brain abscess after sustaining a brain injury which caused her difficulty to breathe and swallow and she developed Bronchopneumonia which ultimately caused her death on 20th April 2013.