Doctors should have done more to diagnose what was causing a young woman to have stomach pains in the hours before her death, a coroner has said.

Twenty-one-year-old Tessa Harker, of East End, Wigton, died at Carlisle’s Cumberland Infirmary on March 6 last year after an ulcer in her stomach, which had initially gone undetected, burst.

Speaking at the inquest into her death, coroner Dr Nicholas Shaw said that staff tending to her should have tried to identify the problem earlier.

After being seen by consultant Frank Hinson on March 4, Miss Harker, who worked at a Carlisle care home, was diagnosed with a “non-specific abdominal pain”.

Dr Shaw was told that registrar Shaker Alseifi had made a recommendation to Mr Hinson that Miss Harker have a CT scan when he arrived on the ward on the morning of March 4.

However Mr Hinson decided that a scan should not be undertaken, as he did not want to expose a young woman to unnecessary radiation.

Dr Shaw asked: “Mr Alseifi recommended a CT scan. Why did you did not request a scan?”

Mr Hinson said he did not believe Miss Harker had suffered an abdominal perforation, adding that although a scan had been recommended, it did not mean one must be carried out.

He said: “When a consultant comes onto the ward then we start the assessment off from scratch.”

Mr Hinson was asked why he had not checked Miss Harker’s National Early Warning Score (NEWS), which is used to monitor any changes in a patient’s condition. He said: “I don’t know. I can’t answer that.”

Miss Harker did have a CT scan the following day, which revealed she had a stomach ulcer which had burst.

A written statement by Dr Julian Thompson, an anaesthetics consultant at North Bristol NHS Trust, said that had Miss Harker received a scan 24 hours earlier, then the ulcer may have been found.

However, he added: “Identifying the ulcer would not guarantee the ulcer would not perforate.”

Miss Harker, who had previously battled with eating disorders, was first taken to hospital after complaining of stomach pains on March 1, but was later sent home.

She went to the Cumberland Infirmary’s accident and emergency department again the following day and, although she was admitted to a ward overnight, she was sent home the following day.

On the first day of the two-day inquest at Cockermouth, Robert Powley, Miss Harker’s fiance, had described how he had originally been told that staff would be undertaking a CT scan.

However, when he rang the following day, he was told that a scan would not be taking place. He then said both he and Miss Harker’s mother visited a few hours later they found her in a single-bed room, covered in vomit.

Mr Powley said that he met Mr Hinson and asked why she had not had a CT scan. When asked about the conversation he had with Mr Powley, Mr Hinson said: “I was uncomfortable talking about procedures for an adult patient while they were in the bed.”

Dr Shaw concluded that Miss Harker, who grew up in the Maryport area, died from natural causes, which were exacerbated by delays in treatment.

Summing up, he said: “I feel that more should have been done to establish a diagnosis before the weekend.”

He added: “I am of the opinion, having read the statement myself, that had Tessa been involved in an attempt to find a firm diagnosis then she would have had a better chance of coming through this than she did.

"I personally feel a more vigorous investigation should have been undertaken on the Friday morning as per Mr Alseifi’s recommendations.”

Statement issued by Stephen Eames, chief executive at North Cumbria University Hospitals NHS Trust

"I wish to extend my sincere apologies and deepest sympathy to the family of Tessa Harker. The trust acknowledges the conclusion of the HM Assistant Coroner.

"Patient safety remains of paramount importance to the trust and it has been recognised through our investigations and in the inquest that the care provided to Tessa fell short of what we would expect.

"As a direct result of this incident, lessons have been learned and a number of actions have been put in place that we believe will further improve patient safety at the trust.

"We will also carefully consider all of the evidence heard at the inquest."