When a young mother complained to paramedics she was suffering chest pains, cold sweats and her lips were going black, she was told to take Panadol and follow up with a GP.
Within 48 hours, she was dead.
On Wednesday, a South Australian coroner found Jennifer Collins, 30, would likely still be alive if not for a series of missteps by those overseeing her treatment.
Deputy State Coroner Ian White said vital information was not passed on from paramedics to hospital staff, doctors missed a blood test that could have prevented her misdiagnosis and a heart rate reading was incorrectly transcribed at a crucial juncture in her care.
"In light of the findings made above, I find Ms Collins’ death was preventable," he said in his report.
Ms Collins died on September 6, 2018, leaving a six-year-old son.
She was "very empathetic and kind", but had struggled through her life with childhood trauma, abuse and drug addiction, her doting brother Bryon told the coroner.
Her cause of death was determined as infective endocarditis; a rare inflammation of the heart's lining, but which is more prevalent in intravenous drug users.
Shortly before her death, Ms Collins was attempting to kick a crippling meth addiction - a critical factor in the misdiagnosis of her condition and the decision-making of medical staff.
She first called triple zero on August 20, describing herself as having a heart attack with tightness in her chest and difficulty breathing.
However, due to her tight financial circumstances, she elected not to go to Port Noarlunga Hospital via ambulance and was instead driven there by her stepfather.
This resulted in a disconnect in communication, as paramedics were not able to advocate her condition to hospital staff, Mr White found.
The hospital subsequently decided not to investigate her condition using a blood culture test, a "pivotal decision", according to the coroner.
"I find that if this had been done then, her death was likely to have been prevented as infective endocarditis would have been identified," he said.
Instead, the possibility of Ms Collins having infective endocarditis was "inappropriately discounted" and the incorrect decision to discharge her was made.
On September 4, her brother Bryon made another emergency call to SA Ambulance Service, reporting she was suffering major chest pain, was breathing rapidly, had a yellow complexion, and her lips were going black.
Shaun Falls, an experienced and "extremely competent" paramedic, attended her home and tested her vital signs.
He found them all to be within acceptable ranges, except for Ms Collins' heart rate which was slightly elevated, so advised against going to hospital and told her to follow up with a GP.
However, in manually transcribing Ms Collins' readings, he incorrectly recorded her pulse as 110 bpm and 112 bpm, instead of 136 bpm and 137 bpm, which should have raised a red flag.
Mr White said the paramedic may have downgraded Ms Collins' priority assessment and cancelled ambulance transport too hastily.
"I am concerned that Mr Falls may have either consciously or subconsciously assessed her as a drug user seeking to withdraw from her habit and that her body was suffering the physical consequences," the coroner said.
Ms Collins died two days later.
Mr White recommended medical staff be better educated on the diagnosis of infective endocarditis and the higher risk experienced by drug users.
He also urged a review into information-sharing between SA hospitals and the ambulance service.
