A "remarkable and kind-hearted" woman died after doctors and nurses failed on 18 attempts in four hours to give treatment at Kingston Hospital.

58-year-old Kamalaloginidvi Pararajasingham, who ran a convenience store in Surbiton with her husband, died from sepsis last November. Family members raised concerns at the inquest into her death yesterday, over the length of time it took doctors and nurses to start treatment. No medication was given to Mrs Pararajasingham before she died because a string of medical staff could not insert a cannula in order to give intravenous drugs.

Doctors told West London Coroner’s Court that staffing levels and annual leave had put pressure on the department when Mrs Pararajasingham, of Selbourne Avenue, was admitted on November 17. The inquest heard that for an emergency department of Kingston’s size, the Royal College of Emergency Medicine recommends 16 consultants booked to work in a standard week, but Kingston Hospital had just six on rota at the time. Coroner Chinyere Inyama concluded that there were “missed opportunities” to “provide treatment that might have altered the outcome” as Mrs Pararajasingham’s condition deteriorated. Two doctors from Kingston Hospital told the court it was a case which has led to an overhaul of protocol in dealing with sepsis patients.

Although the infection was noted as part of the initial assessment, Mrs Pararajasingham was not deemed a cause for concern and so the escalation through to consultant level was slow, the inquest heard. Mr Inyama said that a patient in Mrs Pararajasingham’s condition should be checked every hour, but that because of staff’s repeated attempts to insert a cannula, regular observations were interrupted.

Rachel Vivian, a consultant in emergency medicine, was leading a team looking after 70 patients that day. Mrs Pararajasingham’s daughter, Suji Sululsa Pararajasingham, who is also a doctor, told the court of her mother’s early life in Jaffna, Sri Lanka, and of her eventual move to the UK to settle in Surbiton.

Workers determined soon after she arrived at accident and emergency that Mrs Pararajasingham had some kind of infection and needed intravenous fluids. Staff nurse Amelia Harris told Mr Inyama a healthcare assistant undertook that task. He was unable to place a line before Mrs Pararajasingham was moved. A nurse tasked with cannulation also failed, and about two hours later more attempts were made using ultrasound but these too were unsuccessful.

Dr Vivian then tried herself four times but was unable to place a line. A registrar was asked to place a central line, a longer tube which is placed in a larger vein, but before she had done so successfully Mrs Pararajasingham went into cardiac arrest. The new protocol for staff to deal with sepsis within a set timeframe is due to come into force within the month.