THE family of a young woman who died in hospital from a "massive" blood clot are to make a complaint after an inquest heard of a number of inexplicable delays and decisions.

Gemma Gill, 20, died at Westmorland General Hospital on Easter Saturday, just hours after being discharged by doctors, in what the coroner described as a "one-in-ten thousand" tragedy.

At Kendal's County Hall on Tuesday, family and friends packed into an inquest to face representatives of Morecambe Bay Hospitals NHS Trust and hear doctors admit that things might have turned out differently.

The popular hairdresser, from Hill Close, Kendal, died in the early hours of the morning after developing leg pain four weeks after having surgery on her varicose veins. After being told the pain was simply her leg healing, a blood clot in Miss Gill's left leg travelled to her lung.

Miss Gill, who worked at Joan Adele Hair Salon, in Lowther Street, Kendal, and who had just got engaged to long-term boyfriend Jason Partington, had undergone an operation at Furness General Hospital on February 28 this year after becoming self-conscious about a varicose vein in her leg.

Her mother, Jacqueline, told the inquest she had been "fine" for three weeks afterwards and had returned to work when the pains began.

Miss Gill had told a nurse about her concerns on Wednesday, March 23, and after the pains worsened, she visited a GP the following day. She was told the pains were part of the healing process following her operation.

By Friday, Miss Gill was "crying in pain" and that evening collapsed at home with breathing difficulties and chest pains.

Mrs Gill accompanied her daughter, by ambulance, to the A&E department at Kendal's WGH shortly before 7pm to be told the machine needed to test for blood-clotting (a D-dimer test) had broken. A sample was sent by taxi instead to the Royal Lancaster Infirmary and Miss Gill was told to go home and wait.

"The doctor that was on said she didn't think it was due to the operation on her leg. She said to go home and if we didn't hear from them to assume that everything was fine," Mrs Gill said.

At 1.15am the hospital called and asked Miss Gill to return. An hour later she was seen by a different duty doctor (the original consultant had gone off duty at midnight) and at 3am instructions were given for Clexane (a form of the blood-thinning drug, Heparin) to be administered. It was more than an hour before she was given the drug and shortly afterwards Miss Gill passed away.

Mrs Gill, who described her daughter as a "second mum" to her younger brother and sister Jake (six) and Morgan (four), recounted the events that unfolded after they were asked to return to WGH: "Gemma was in a wheelchair because she couldn't walk at this point. She wasn't breathing properly, was complaining of an aching in her chest and had a racing pulse.

"They said they thought it could be a blood clot on her lung and that when they got her onto a ward they would inject her with something to thin the blood. It was a while before we went onto the ward. I went up with her and was helping her on with her nightie when she said she was going to be sick. That was the last time I saw her."

Sydney Schneidman, a consultant at RLI and lead physician at WGH, was not on duty that night but gave evidence on behalf of Dr Belgraver the first physician who saw Miss Gill who has since moved abroad.

He told the inquest Miss Gill had a rapid heartbeat at the time she was discharged. He admitted the signs had been "worrying" and that while it was not unusual, it was "worrying that a patient would be sent home with (her) symptoms". He agreed he would have transferred Miss Gill to another hospital where more tests would have been available.

Asked why doctors had delayed in seeing Miss Gill after her return to WGH, Dr Schneidman said he "did not have the answer". When Mr Smith questioned whether transferring Miss Gill to RLI would have made a difference he said: "It is possible but it is difficult to know for sure. There are a lot of ifs."

Isabel Huggett, a consultant physician at WGH, arrived on the ward around the time Miss Gill's condition worsened. She admitted there had been a delay in administering the drugs but that "events had overtaken" staff and that the timescale was "unlikely" to have made a difference.

"It's unlikely that a very large clot would have formed during that time," she said. Dr Huggett also admitted that if a pulmonary embolism was suspected, Heparin should have been given as soon as possible.

Thomas Calvey, the consultant vascular surgeon who performed Miss Gill's original operation said he had performed "well over 2,000" similar operations and that if a blood clot were to develop post-op, it would normally do so within 48 hours.

"Blood clots are phenomenally difficult to treatdespite the best medical or surgical management," he said.

Summing up, Mr Smith said: "The doctors have been open and honest about what happened and they have accepted that at certain points in events they can't really explain delays and decisions that might have been made."

He added that doctor's notes on the night "were perhaps not as clear as they could have been" and that the reasons for delays had not been made "abundantly clear".

"The doctors have made no bones about the facts that occurred. They've been open, straight and honest. Any operation does carry a risk even if that risk is just one in 10,000. Gemma appears to have been that one in 10,000."

After a verdict of natural causes was recorded, Ranu Rowan, legal adviser for MBHT, offered her condolences to the family. "Gemma was obviously a very special girl and I know that the staff have been very upset by the events," she said.

Speaking after the inquest, Mrs Gill told The Westmorland Gazette she was satisfied with the outcome of the inquest but planned to make an official complaint through MBHT.

"(The coroner) made it clear that time was wasted and that something could have been done quicker. They sent her home again and again what was that idea? It doesn't make it better, it doesn't bring her back but we got the truth out today that they could have done something more than what they did.

"I'm glad it's over with. It's been eight months now and (the inquest) brought it all back again. Life isn't the same, it changes you beyond all belief. We've got to live with what happened for the rest of our lives.

"Gemma was a special person. She had just got engaged, she was learning to drive, she had booked her 21st birthday. She had her whole life in front of her."