A coroner has today said that out of the hundreds of inquests she has heard, she was 'particularly troubled' by the death of a Peterborough father of two, left waiting at a GP surgery for three and a half hours.
David Dixon-Currie, 50 died in hospital after hours of deteriorating at the doctors surgery where nurses failed to pick up that he was developing cardiac arrest.
Nurses at Old Fletton Surgery in Peterborough thought his deterioration was gastroenteritis and ordered a 'non emergency ambulance' before calling his wife to bring new clothes.
But when David suddenly grew pale and breathless, it became clear he was in cardiac arrest, an emergency ambulance was called and he was rushed to hospital.
Assistant Coroner Rosamund Rhodes- Kemp today, Wednesday November 21, concluded that David's death was due to 'natural causes' and added that 'among hundreds' of other inquests this particularly 'troubled' her.
She said: "If Mr Currie had got to the hospital sooner and if he had not died when he did, his wife may have had the opportunity to be with and he would have been more comfortable than he was.
"He had spent three and a half hours at the surgery. If an ambulance had been called sooner it is not clear that it would have made a difference if he had gone to hospital sooner.
"The only possible cause of death is natural causes."
The inquest heard that David's wife, Caroline Currie, 49 was ushered into a private room at the surgery and refused access to husband David, 50 after being told doctors were 'stabilising his breathing'.
The mum-of-two recalled hearing frantic nurses shouting 'blue light' and seeing 'medics with defibrillators' shortly after arriving at the surgery at a nurse's request.
Frantic Caroline was told by nurses at Fletton Surgery in Peterborough that David had a 'diarrhoea incident' after he arrived at the surgery having complained overnight chest pain.
She had rushed to the surgery on October 3, 2016 with clothes for him but receptionists told her to 'sit down and wait' because there were ' too many people in the room'.
Caroline told the inquest at Huntingdon Coroner's Court today: "I heard ambulance sirens and saw medics running past.
"One nurse said 'blue light' while I was sat in reception and I thought that this could not possibly be for David."
She asked a receptionist: "Can I at least go in and help him? I have his clothes." to which she was told "no, sit down and wait. There are too many people in the room."
While Caroline waited nervously in the waiting room, David had gone into cardiac arrest and doctors were attempting to restart his heart.
Caroline remained unaware for 'an hour and a half' that David was dying and grew increasingly worried when she was moved to a private room with another nurse who was making small talk with her.
She added: "I asked again and again when I could see him and I was repeatedly told 'they are still trying to stabilise his breathing'.
"I gave up asking to see him and grew worried about my children who home with the baby sitter."
She asked to go home quickly to make her twin daughters' food, but the nurse told her she 'would not advise that'.
It was then that she received news that doctors were 'determining the cause of death' .
Dr Kaushik Pillalamarri, who had been treating David that morning entered the room 'shaking'.
Caroline said: "He shook my hand and I could feel him shaking. I said 'when can I see him? Where is David? What is going on?'
"I have been waiting her for an hour and a half. Why have I not been allowed to see my husband?
"He shook his head and said 'it is not looking good. We are running tests to determine the cause of death.'
"I turned to him and said 'cause of death? Is my husband dead or is he alive?"
To which Dr Pillalamarri allegedly replied: "I apologise Mrs Currie, I used the wrong terminology. They are still trying to restart his heart."
While Caroline waited next door paramedics had rushed David to Peterborough City Hospital with a defibrillator connected to him where he was declared dead at 3pm.
A post mortem concluded that David died of acute left ventricular failure which was complicated by gastroenteritis.
Earlier in the day, David a former telemarketer, had arrived at the surgery for an emergency appointment after experiencing hot and cold flushes, chest pain and back pain.
However, one nurse told the inquest that 'at no point' since he arrived at the surgery for his 10.30am appointment, did he complain about chest pain.
Claire Stilgrove said: "If he had told me he was experiencing chest pain that morning we would have called for an ambulance straight away.
"When he phoned that morning he also did not have chest pains."
When David arrived at the surgery that morning the inquest before assistant coroner for Cambridgeshire Rosamund Rhodes-Kemp heard that David told receptionists he felt 'unwell' as he 'leaned over the reception desk' with 'his head down'.
David was later found on the surgery bathroom floor after throwing up and was taken by nurses in a wheelchair to the observation room.
A non emergency ambulance was then called and was due to arrive in the hour but when he suddenly grew pale and breathless, it became clear he was in cardiac arrest and an emergency ambulance was called.
Dr Pillalamarri told the inquest that at the surgery he only showed symptoms for gastroenteritis and those alone would “not qualify for a 999 call”.
He added that had David reported chest pains at “any point during his time” at the GP surgery, he would have upgraded the non emergency call to a 999.
He said: “I could never have guessed it was acute ventricular failure in my wildest dreams.
“If only he had said to us he had chest pains. We have an ECG machine in the next room.
“But when I asked him what he felt he never said he had chest pain.”.