Tragic details have emerged into how a teenager died from sepsis which wasn't initially diagnosed.
Abby Holgate, who was from Newark, died aged 17 from sepsis and leukaemia on March 17 2021 at King's Mill Hospital, a post-mortem examination found.
Assistant Coroner Elizabeth Didcock is examining the circumstances surrounding Abby's death.
The inquest, which started at Nottingham Council House on Wednesday (February 16), was told that, despite having an infected tooth with an abscess, and presenting to healthcare organisations on a number of occasions in pain through February and March 2021, sepsis was not at first detected.
Sepsis is a potentially life-threatening condition where the body's response to infection causes injury to its own tissues and organs.
Abby attended King's Mill Hospital on March 16 with sepsis, enlarged lymph nodes and an abnormal blood count, before becoming unresponsive in the morning of March 17.
Full resuscitation was attempted, but she could not be revived.
Her family, who were in attendance at the Council House virtually via Microsoft Teams, had raised concerns including how long Abby had had leukaemia, and what had causes sepsis.
Abby had no significant past medical history and was known to have a phobia of needles.
During proceedings on Wednesday (February 16), the inquest heard how Abby was unwell on February 25 with toothache, a fast heart rate and had lost weight.
The family called 111, again on March 5 due to her heart rate and on March 8, due to dizziness, lethargy and a rash.
Abby was taken to King's Mill Hospital by East Midlands Ambulance Service on March 8 and into the early hours of March 9.
She was back at King's Mill on March 12, and was referred there again on March 16 after visiting her GP and appearing unwell, where she was taken by ambulance and admitted.
She was then treated for sepsis and returned abnormal blood tests which were described as 'very worrying' by Ms Didcock.
Abby then became unresponsive and died in the early hours of March 17.
The pathologist conducting the post-mortem ruled she was more prone to sepsis because of leukaemia, and that she died of natural causes likely because of her dental issue.
Noreen Holgate, Abby's grandmother, said during proceedings: "It all happened so quickly, there were no signs of it at all.
"She was starting to drive and then she was just gone."
Mother Angela Holgate said: "It was too quick."
Abby was registered at Barnby Gate Surgery in Newark, and, other than her dental problem, she was described as 'fit and well' with no regular medication.
She had attended Newark Urgent Care Centre three times in February and March 2021, and only a fast heart rate was detected during her last visit there on March 6.
Abby was called an ambulance on the evening of March 8 while she had ongoing issues with her tooth and was in pain.
In a statement, Christina Bailey, a Nottinghamshire driver for East Midlands Ambulance Service, who attended the call that evening, said: "Abby had a heartrate of 140 beats per minute.
"Our observations found that we needed to take her to King's Mill Hospital for further treatment, as there was an early indication of what could have been sepsis.
"While she did not need oxygen, I said we needed to start treatment through intravenous fluids and a canular.
"But she refused after I continued to explain why and persuade her."
Ms Didcock explained Abby had a national early warning score of four, which meant paramedics had to take her to hospital.
That score is used to detect and respond to clinical deterioration in patients.
Abby was then taken and treated at hospital overnight into March 9, where her heart rate had come down and concerns about sepsis had gone as she was assessed her early warning score had come down to two.
She was then discharged later that morning.
But no record was taken of a doctor examination, and, although Ms Didcock was satisfied one had taken place after hearing evidence and further statements, she said it was 'concerning'.
During proceedings, mother Angela said: "I remember waiting a long, long time, but a doctor did come to see her."
The inquest continues.
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