A Home Office Pathologist was called in to investigate the death of an 86 year-old woman following concerns over a possible delay in her treatment.

Sarah Dilys Thomas died on March 8th 2006, but confusion between medical workers and care staff at a Johnston nursing home prompted coroner Michael Howells to call in a specialist pathologist.

The inquest in Milford Haven yesterday was told that A&E staff at Withybush Hospital said they had been informed that Mrs Thomas had been in a serious cyanosed condition, where the body takes on a blue colour due to lack of air in the blood, since 2.30am.

But the matron/manager, nurses and carers at Fairfield said that she had been fine at 2.30am but at 5.30am, when it was noticed her extremities were blue, oxygen was administered and an ambulance called.

Her daughter, Avril Harry, said that two days before her mother's death she had drawn attention to her breathing but was assured she was fine. "Her breathing was horrendous, she was gasping and slumped over the side of her wheelchair," she said.

Fairfield matron/manager Gail Fransham and staff members said that Mrs Thomas was checked at regular intervals.

She had been sleeping at 2.30am but was having breathing difficulties and was cyanosed at 5.20am, they said.

A&E staff nurse Dawn Lloyd and Senior Consultant Dr Parks expressed concern about the apparent delay in treatment, and their concern prompted the coroner to order Forensic Pathologist Dr Andrew Davidson's investigation.

Dr Parks said cyanosis was a serious pre-arrest condition indicating respiratory decline, which required urgent attention.

Mr Howells read a statement by former Fairfield Nurse Wendy Bowen who stressed that Mrs Thomas was fine at 2.30am and had been treated as soon as cyanosis was noticed. She emphatically denied any delay: "I would have been risking my registration if I left it until 5.30am before calling the ambulance".

The Pathologist said death was due to septicaemia, the precise cause of which had not been identified, in a patient with chronic renal failure.

The Coroner said there was some confusion and doubt about what was actually said to cause concern about a possible delay. He recorded a verdict that Mrs Thomas died following unsuccessful medical attention for a life-threatening condition.