A CORONER says it was "inexcusable" that a Toowoomba on-call doctor had not charged his mobile phone and was not informed that Verris Dawn Wright was deteriorating at Oakey Hospital on Boxing Day 2013.
Queensland Deputy State Coroner John Lock on Friday handed down his findings into the death of Mrs Wright, 86, and that of Jasmyn Louise Carter-Maher, 17, who died at Warwick Hospital in similar circumstances.
Both women died of sepsis - an infection - seven months apart and Mr Lock said clinical staff had failed to recognise and explore this possibility when both patients were hospitalised.
In Mrs Wright's case, Mr Lock said she was first taken to Oakey Hospital on Christmas Eve 2013 with abdominal pain and was later discharged.
Two days later she went back to hospital and was not seen by a doctor for four hours. She died during this time.
"There were a series of almost unbelievable errors, misunderstandings and miscommunications which contributed to this tragic set of events," Mr Lock said.
He said the nurse had one plan; for the on-call doctor to examine her. Mr Lock said the doctor's phone was not charged and did not receive the nurse's messages.
Mr Lock said this was "inexcusable" and that nurses should have had a Plan B.
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