The heartbroken husband of a woman who died after healthcare staff mistook her life-threatening condition for a minor illness has called for urgent changes to the system that failed her.

Prabhanjan Behera, 38, said his "world came crumbling down" after Madhumita Mandal died of multiple organ failure and sepsis caused by an ruptured ovarian cyst at Croydon University Hospital in September 2013. 

Despite being gravely ill, the 30-year-old IT worker did not receive intensive treatment for more than four hours after reporting to the hospital's urgent care centre, run by private contractor Virgin Care. 

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Her condition was initially deemed not to be an emergency by a receptionist with no medical training, before an A&E doctor misdiagnosed her illness as gastroenteritis, further delaying treatment.

Mr Bahera, who lived with his wife in of Paul Gardens, Croydon, before her death, said: "Losing Maddie has changed my life completely – I feel like I’ve lost everything and my world came crumbling down.

"I have been left absolutely devastated by this nightmare – we had everything to look forward to and were hoping to start a family of our own."

He added: "I feel that there were a number of occasions that if doctors had intervened and treated her sooner, she would still be with me today.

"Every second counts when you are in hospital and I feel that Maddie’s condition was not taken seriously enough to begin with.

"To have non-medical staff making these potentially life or death decisions seems to be unacceptable to me and I would hope that medically qualified people will be making decisions in future."

Mrs Mandal died two months after Care Quality Commission (CQC) inspectors noted Virgin Care patients were “streamed" for treatment by non-clinical staff. Their concerns were not published until after her death.

Receptionists were encouraged to ask doctors for advice, but some staff members were “not comfortable” with the process, the inspection report said.

The CQC said: “We were concerned that there was a risk of a patient with a serious illness or injury being wrongly streamed and their condition deteriorating.”

Non-clinical staff are still responsible for "streaming" patients at the urgent care centre, although every patient should now be seen by a nurse or doctor within 20 minutes of arrival.

Coroner and doctors raise concerns about 'streaming'

Dr Kathryn Channing, lead consultant at Croydon University Hospital's emergency department, told an inquest into Mrs Mandal's death yesterday that clinical staff had "never been happy" with the system.

She said: "I think I can speak for both my colleagues and myself when I say that clinical staff conducting the streaming would be more appropriate.

"We have pressed it since it started and raised our concerns about it but the contract is with the CCG and Virgin Care, not the trust."

Senior coroner Selena Lynch is to write Croydon Clinical Commissioning Group to express concerns over the "streaming" system, which has previously been endorsed by the Department for Health.

She told the inquest at Croydon Coroner's Court: "There is a possibility that her death was contributed to by failings in care and her death was preventable."

"There were several cumulative delays in the urgent care centre and emergency department in assessment and treating her."

Both Croydon CCG and Virgin Care have been approached for a comment.