Misdiagnosis led to malaria death

Mathilda fell ill after returning to Cardiff from Uganda

The death of a Cardiff University student from malaria could have been prevented, a coroner has said.

Mathilda Cooper, 19, contracted the disease in Uganda and died a few days after returning to south Wales.

After falling ill, the court heard that she contacted both NHS Direct and her GP, but was diagnosed with flu.

Recording a narrative verdict, coroner Mary Hassell said that with the right treatment her condition was "probably curable".

The inquest heard from Dr Ashley Croft, one of the UK's leading experts on tropical diseases, who called for procedures to be strengthened.

The system failed, it fell down Mathilda Cooper's mother

He said: "It was a diagnosis that shouldn't have been missed but it was, with tragic consequences.

"Something in NHS protocols needs to be strengthened. The fact information about her trip to Uganda got lost is quite wrong."

The inquest heard how Miss Cooper, originally from Burrington, Devon, had been visiting her father in Uganda for Christmas.

She had not taken anti-malarial drugs because she had previously lived in Africa, and as a frequent visitor, thought she was immune to the disease.

The politics, philosophy and ancient history student, was feeling unwell by the time she arrived back at her halls of residence in Cardiff in January 2006.

Friend Helen Wheeler said: "She was tired and not her usual self and said she had flu-like symptoms.

She was told during a face to face consultation she had flu. This was not the case Coroner Mary Hassell

"It was unlike her. She said she had felt ill for a couple of days."

Ms Cooper's condition worsened over the following days, and she displayed symptoms including general tiredness, nausea and upset stomach.

She contacted NHS Direct on her friend's behalf and advisers asked Ms Cooper a series of questions - including whether or not she had recently been abroad.

She was diagnosed with flu and told to see her GP.

The following day she visited her doctor but was not asked if she had been abroad, and did not volunteer the information, so malaria was not suspected.

She was diagnosed with a viral infection and told to return if she continued to feel unwell.

But within four days, the student died, and was discovered in her room by Ms Wheeler.

Malaria can be spread by through mosquito bites

Recording a narrative verdict, Mary Hassell, coroner for Cardiff and the Vale of Glamorgan, said: "I have no hesitation Matti died from malaria.

"In that sense she died from a natural cause, but in this situation it doesn't adequately reflect the sequence of events.

"On 22 January, she was told during telephone conversations with the NHS Direct and the out of hours doctor service, she had flu. This was not the case.

"On 23 January she was told during a face-to-face consultation she had flu. This was not the case.

"Matti died on 26 January from cerebral malaria.

"It was not diagnosed because health professionals did not elicit the information she had been in a high-risk malarial area, or they elicited the information but did not recognise the significance of this."