Mum-of-three Tracey Ketchen, 41, suffered fatal heart failure brought on by asthma hours after she was admitted to Queen Alexandra Hospital, Cosham, Portsmouth.

An inquest into her death was told of a string of concerns over her care in her last hours.

Coroner David Horsley has written to Portsmouth Hospitals NHS Trust calling for a review of procedures after hearing how:

Mrs Ketchen's asthma was diagnosed in 1994 and written on her GP notes, but her family say she was never informed.

When her fingertips turned blue, a nurse called a doctor, but the doctor never arrived. It turned out the nurse had bleeped a number for a doctor who had gone off his shift.

Mrs Ketchen wasn't hooked up to a finger monitor which would have alerted doctors and nurses when she stopped breathing. A cardiac arrest team was only alerted after a nurse noticed her chest wasn't moving up and down.

A nurse – one of two on the ward – went on an hour-and-a-half break when there was an emergency on the ward.

Now Mrs Ketchen's husband Nicky is to sue the hospital, claiming if she had received the right care she would still be alive.

A Portsmouth inquest into Mrs Ketchen's death heard that doctors put her on oxygen therapy after diagnosing her with an inflammation of the lungs caused by smoking when she was admitted to hospital on December 19, 2006. It was only during a post mortem examination that the hospital discovered that Mrs Ketchen, formerly of Botley Drive, Leigh Park, had acute asthma.

The inquest was told that even if hospital doctors correctly diagnosed asthma, it probably would not have saved her life because oxygen therapy is given for respiratory conditions like asthma in the early stages.

But coroner David Horsley had serious concerns about Mrs Ketchen not having a finger monitor.

He asked: 'If the monitor had been on her finger would it have made a difference?'

Dr Paul Schmidt, who treated Mrs Ketchen, said: 'Possibly. But it's 50/50.'

He added: 'It may only have been a minute or two, but that minute or two can sometimes make a difference.'

Barrister Lucy MacKinnon, representing Mr Ketchen, told the inquest: 'The evidence is that there was a lack of basic care and that would have contributed to the events that unfolded.'

Mr Horsley recorded a verdict of death by natural causes, but said he would write to the hospital trust calling for improvements.

He said: 'From the evidence I have heard, if the monitor had been on the alarm might have been raised earlier, and the resuscitation team started.

'It is a possibility her life would have been saved. However, the evidence is that it's no more than a possibility.

'Therefore I am unclear that neglect contributed to her death.'

Mrs Ketchen's family were not happy with the verdict. Mr Ketchen said: 'I don't agree with it really, but there's nothing you can do about it.

'I think what happened was poor. I did not even know she had asthma.

'She should have been put on an intensive care ward earlier. If she had she would still be here.'

Mr Ketchen is in the process of a clinical negligence case, which will be subject to later civil proceedings.

Trust offers sympathy for death: Click Next Page

Duty doctor never got nurse's call: Click here.

'Doctors never told Tracey she had asthma': Click here.