Christine Arnold, 63, had been confined to her house for years before she was rushed to Hinchingbrooke Hospital, Huntingdon, where she died at 7.45am on July 21, 2011.
She had been admitted the previous morning when her friend, Susan Ward, called an ambulance to her Nene Road home.
On day three of the inquest on Thursday (October 18), deputy coroner Belinda Cheney, sitting at Lawrence Court in Huntingdon, heard evidence from consultant psychiatrist Claire Royston that suggested the health agencies involved with Mrs Arnold had “missed opportunities” to engage with the mother-of-three.
Mrs Arnold, who weighed 28 stone, had been confined to a single bed in her living room for months and had blisters on her abdomen and a hole in her abdominal wall, which was the result of having fallen out of bed five days before her death.
The Hunts Post reported last week that Mrs Arnold had a catalogue of conditions, but because of her personality and the continual cancellation of appointments, the NHS physical disabilities team seemed reluctant to work with her. She was also discharged from the care of an NHS mental health team in 2006.
Despite being known to have a personality disorder, Mrs Arnold was deemed to have the “capacity” to make decisions about her care, the inquest was told on Thursday.
“It was the consequences of her personality disorder rather than agoraphobia that led to her making the unwise decisions not to accept help,” Ms Royston said. “She was competent to make decisions and was able to consent to care. The difficulty lay in her ability to engage in the process.”
However, Ms Royston added it was clear Mrs Arnold would engage with certain people, and these opportunities should have been used as a platform on which to build a relationship with her – helping her to make fewer “unwise” decisions.
Dr Dennis Cox, who submitted an independent report to the coroner, said Mrs Arnold should have been treated as a priority and her GP, Dr Edward Rej, who twice prescribed antibiotics over the phone, should have made more of an effort to visit her.
On Saturday, July 16, Mrs Arnold had “uncharacteristically” called the out-of-hours doctors service complaining of excruciating pain after falling out of bed.
Dr Rej said he had called Mrs Arnold on Monday to say she would receive a home visit that day but that he could not guarantee he could go personally.
Mrs Arnold elected to wait until Wednesday for the home visit, but was rushed into hospital that morning.
“There was an opportunity to go and see her when she called, uncharacteristically, to say she had a urine infection,” Dr Cox said.
“She also said she was bleeding from the back passage, and you can’t make a confident diagnosis that it’s piles. How do we know it’s not rectal cancer?
“I do think the situation should have been addressed and not taken at face value. On the balance of probabilities he [Dr Rej] should have visited her that day.”
The inquest was adjourned so the coroner could gather further evidence from Hinchingbrooke Hospital as to whether Mrs Arnold’s life could have been saved had she been admitted to hospital earlier.