A Parkinsons sufferer who contracted an antibiotic-resistant superbug died having not been seen by a specialist doctor for more than 24 hours after he arrived in Kingston Hospital A&E – on a day when some nurses were looking after three times more patients than they should have been.

Charles Gallagher died of mass organ failure caused by overwhelming septicaemia on June 3 last year.

At his two-day inquest, which started on Monday, south west London coroner Chinyere Inyama concluded that there were "missed opportunities" by hospital staff that likely "contributed to his death".

The 83-year-old walked into Kingston’s A&E on June 1 at about 2pm with a blocked catheter.

The carer who brought him told the court Mr Gallagher had waited 25 hours for an ambulance at his home opposite the hospital in Galsworthy Road, but one never arrived.

London Ambulance Service (LAS) has since disputed the evidence offered in the inquest by Mr Gallagher's carer. The LAS state an ambulance was sent and treatment offered to Mr Gallagher after a fall on May 31 but he was not taken to hospital. 

The LAS said it was called a second time on June 1 at about 10.30am but were told the patient did not require urgent treatment. The LAS said the request was later cancelled at about 1pm.

Junior staff nurse Aideen O'Connor told West London Coroner’s Court that Mr Gallagher had arrived at an extremely busy A&E.

She said: "[A woman] walked him across the road because he was unable to get ambulance for 25 hours.

"I said, 'We need to get him round and into a bed'. There was no room.

"It was just so busy. I really needed to get him re-catheterised.

"Ideally he would have been in majors [the area in A&E for people who require immediate treatment] straightaway."

Mr Gallagher was eventually placed in the minors area, for people who do not require immediate emergency care, because it contained the only available bed.

At that point, minors junior staff nurse Casey Green had been tasked with looking after 30 patients, three times more than normal.

She said: "I came on at 7:15pm and [Mr Gallagher] had already been there for a couple of hours.

"In the handover from the day nurse she just said he was waiting for admission.

"Because of his problems he needed to see a specialist.

"[Patients] are usually seen within four hours but the department was really, really busy.

"They sent someone in to help [but] it was just two of us for 30 patients. I didn't actually get to Mr Gallagher for about an hour.

"I had so many patients and could not give him the attention he needed. Everywhere was at full capacity."

Mr Gallagher needed to be seen by a urology specialist and was eventually transferred to the short-stay acute assessment unit (AAU), but no record could be found of his formal admission or a visit from a specialist doctor.

A doctor had changed his catheter but there were no notes about why Mr Gallagher had waited for so long or why he was he was never properly admitted, the court heard.

Miss Green added: "Because I couldn't leave to take him to a ward, a transfer nurse did it. I didn't even see him leave."

In AAU it was discovered Mr Gallagher had a drug-resistant infection caused by E-coli bacteria, with which he had been diagnosed three months earlier.

After almost 24 hours in the hospital without seeing a specialist doctor, Mr Gallagher was moved into a side room away from other patients, at about 12pm.

AAU nurse Helen Mitchell said: "I knew he had not been prescribed anything, which I thought was a bit out of the ordinary.

"It never entered my head he had not seen a doctor in A&E. To me, you had to see a doctor to be admitted."

Senior house officer Dr Daniel Thompson added: "I went through the notes and it was difficult to get a well-rounded assessment of what was going on.

"There was no mention of urology referral."

The nurse tasked with looking after the side room said she did not notice Mr Gallagher until at least 2.30pm because she was not told he was there.

His blood pressure and oxygen levels were not taken for about 13 hours.

NHS guidelines state all acute admissions should have a minimum of four hourly observations for 48 hours from admission or be completed hourly in emergency departments.

By the time observations were done Mr Gallagher had extremely low blood pressure and was severely unwell.

He died of mass organ failure on June 3.

Dr Aram Salehi told the inquest that Kingston Hospital was implementing procedures that would minimise the risk of a repeat of Mr Gallagher’s case.

He said: "AAU consultants get together every month to talk about problems and trends they notice."

He added that staff were being trained to use a new computer system that would make it easier to monitor patients.

Summing up, Mr Inyama said: "There was a delay that seems to be with the staff not being able to cope.

"Missed opportunities to adequately treat his condition likely contributed to his death."

Mr Gallagher died of natural causes, he concluded.

Jane Wilson, medical director at Kingston Hospital, said: "On behalf of the Trust I would like to offer our sincere apologies to Mr Gallagher’s family.

"We recognise that we failed to provide Mr Gallagher with the care he needed.   

"It is clear that more work needs to be done by the hospital to ensure we do everything we can to make sure handover processes are more robust so that all the clinical teams have the right information to provide the best care to our patients."