The care received by a St Asaph pensioner on arrival at Glan Clwyd Hospital was “very poor”, according to an independent expert.

Karen Hocknull not only had to wait over an hour to be seen by a triage nurse but a junior doctor failed to carry out a proper diagnosis because he was “too busy”.

Although Mrs Hocknull had been able to walk to the ambulance from her home and talk to staff her condition rapidly deteriorated and she died about six hours after arriving at the hospital.

A post-mortem examination revealed that the cause of death was a bronchial pneumonia and a massive pulmonary embolism, or blood clot, but she also had lung cancer which had not been diagnosed.

The inquest in Ruthin heard that Mrs hocknull, of Spring Gardens Caravan Park, St Asaph, saw her GP on June 26, 2017, with a swollen gland in her neck and returned two days later.

On the 26th, after complaining of breathing difficulties, she was taken to hospital in a St John Ambulance as her case was not considered urgent. It was a busy period and she was left on a trolley for over an hour.

She was seen by a junior doctor, Dr Shujah Khan, but he failed to monitor her condition because, he later explained, it was so busy.

Dr Khan no longer works at the hospital and did not give evidence at the hearing.

Mrs Hocknull’s condition rapidly declined at about 9pm and she died despite exemplary procedures at that late stage.

Following her death the Betsi Cadwaladr University Health Borad held its own reviews and John Gittins, coroner for North Wales East and Central, commissioned an independent report from Professor Solomon Almond, consultant physician at the Royal Liverpool Hospital.

He said that because of the lung cancer Mrs Hocknull had a very poor prognosis when she arrived at the hospital. However, her condition had been miscalculated in the ambulamce and she should have been triaged within 15 minutes, and had an ECG and X-ray .

“Despite a number of failings she had an unsurviveable condition,” Said Prof Almond.

He said the explanation given by Dr Khan that he was too busy was “totally inadequate”.

Adam Griffiths, head nurse for unscheduled care, who chaired the internal review, said Prof Almond’s findings were all accepted and steps had been taken to prevent a recurrence, though the pressures on the service were still intense.

“I am comfortable that we have learned from Mrs Hocknull’s sad death,” he said.

The coroner recorded a conclusion of natural causes but said he did not intend issuing a Regulation 28 report to prevent future deaths.

“I am satisfied that the Health Board very quickly identified a number of issues and everything learned has been auctioned,” he said.