An elderly woman fell seriously ill and died after administrative errors at both a doctor’s surgery and hospital, an inquest heard.

Pamela Backhouse, 79, died at Darent Valley Hospital on January 8 having suffered a stroke.

She had been prescribed the drug warfarin, which is used to control the thickness of the blood and prevent clots, by her GP Dr Simon Aburn, who was tasked with monitoring its administration every eight weeks.

However, after Mrs Backhouse cancelled an appointment due to illness on December 10, her condition rapidly deteriorated.

Dr Aburn visited Darenth Grange care home, in Darenth Hill – where Mrs Backhouse lived – on December 14, but did not view her condition as an immediate cause of concern, and spoke with staff about booking another appointment once she felt better.

Margaret Lee, the registered manager of the care home, which the Care Quality Commission said was in need of improvement following its last inspection in November last year, spoke of how Mrs Backhouse had been a popular and highly mobile resident since she moved in back in October 2012.

She said she had “full mobility, enjoyed dancing and was able to walk up and down stairs”, but had begun to suffer from back pain in April of last year.

By November, she had begun to feel pain in her hip and was taking antibiotics, but her condition deteriorated in early December and she started to need help getting around.

As the month wore on she lost her appetite and stopped eating, which led to dramatic weight loss.

During the inquest at Gravesend’s Old Town Hall, Dr Aburn admitted that with hindsight he should have arranged for a district nurse to come and take the blood test at the home during his visit on December 14.

A district nurse eventually took blood, known as an INR test, on December 31.

The level should have read between two and four, but Mrs Backhouse’s was 9.6 and she should have been taken off warfarin immediately.

First to receive the results were staff at Darent Valley Hospital’s blood and science department, which receives the results of all such tests taken in the area and alerts GPs to any that are considered abnormal.

The head of the department, Colin Brisley, told the inquest that the result came in at 3.38pm on December 31, but staff on duty failed to phone it in to the Devon Road surgery in Darenth where Dr Aburn worked.

Only two members of staff were working at the time and one of them was so upset by the failure to report the test result that he took an extended period of leave before quitting his post and moving back to his native Saudi Arabia.

Dr Aburn could not see the result for himself on his computer at work because the surgery had closed that afternoon for the new year break and did not reopen until January 4.

Coroner Roger Hatch was critical of the system employed by the hospital and the surgery to relay results.

He added: “I am not satisfied that the steps taken so far are efficient enough to prevent a similar incident happening again.”

Upon his return that day, Dr Aburn saw the result at around 8.15am and immediately phoned the care home to tell staff to stop giving Mrs Backhouse the warfarin, but by that time she had already been found unconscious and unresponsive by staff.

The retired shop assistant had suffered a stroke and an ambulance was called, which took her to Darent Valley Hospital.

Family were told that her chances of survival were slim and she died four days later. A post mortem gave the cause as a intracerebral haemorrhage on the left side of her brain.

Having heard all of the evidence, Mr Hatch said: “The purpose of this inquest is not to deal with any criminal liability, that is for other courts to decide if needs be.

“The purpose of this court is to ascertain how Pamela Backhouse came to her death.

"Due to the failures in respect to the INR test and result, which contributed to Pamela Backhouse’s death, I am left with no choice but to conclude that the death was due to the failure of Darent Valley Hospital to pass the result of the adverse INR test to the doctor’s surgery, and the failure of the doctor’s surgery to have an adequate system in place to deal with results over the new year period.”