Surgery actions "fell short of neglect".

A teenager died after test results that showed dangerously low levels of potassium in her blood were pushed under her GP’s door while he was away instead of being dealt with as a medical emergency, an inquest heard.

A childcare student, Stephanie Marks, 18, had been due to go into a clinic to receive treatment for anorexia but died of a heart attack in August 2015 before being admitted.

When a blood test showed that she needed urgent medical attention the results were phoned through to the medical centre in Clevedon, North Somerset, at 3.45pm the same day: Friday, July 31.

A receptionist wrote the details on a form but, instead of handing it to the duty doctor for immediate action, she pushed it under the door of Ms Marks’s GP, Stephen Pill, who was away.

Dr Pill found the results when he returned but faxed them to an eating disorder clinic where he wrongly thought that Ms Marks was being treated. In fact she was not due to be admitted for another three days.

The results were not found until staff arrived at the Steps clinic at Southmead Hospital in Bristol on Monday, August 3, when Ms Marks was due to start treatment. It was already too late. Her body had been found at her home in Clevedon the previous day by her mother, Lynne.

Ms Marks had been to the doctor’s nearly every day in the fortnight before her death complaining of pins and needles and chest palpitations.

The inquest was told that her abnormal test results should have been handed straight to the on-duty GP.

Assistant coroner for Avon, Simon Fox, QC, said that the actions of staff at the medical centre fell short of neglect, and that the medical cause of death was sudden cardiac arrest in the context of anorexia and hypokalemia.

Changes have since been made at the practice. Urgent notes are now handed to doctors who are required to sign for them. Ms Marks’s mother said that the changes were “too little, too late.”