A doctor’s surgery has changed a procedure after the death of a 35-year-old mum to start flagging up patients needing hospital referrals.

Until mum-of-two Lisa Stewart’s death from a heart problem, the onus was on patients at Farfield Surgery in Keighley to get in touch with their doctor for test results and to arrange a referral.

Mrs Stewart of Oakbank Drive, Keighley, had been to her GP about palpitations and panic attacks and despite being on beta blockers had undergone normal ECGs in the past. But when her palpitations got worse, doctor Michel Gabbitas sent her for another 24-hour ECG, telling her to contact him again when the results came back and organised for her to have more blood tests.

Yesterday a Bradford inquest heard when Mrs Stewart had later telephoned the surgery and was told the blood results were normal, no mention was made of the ECG results which had also come back with a note saying she should be referred to cardiologists.

Her family told the inquest when she had been told the blood results were normal she got the impression everything was alright and that was why she did not go back to the doctor.

But she died despite resuscitation attempts on March 26 last year. She had been out with her family the night before and gone to bed as usual, but her partner had found her collapsed after hearing her laboured breathing.

Giving evidence, GP Dr Gabbitas said he did not really class himelf as her doctor and thought she had come back and seen one of his partners instead – although he later realised she had not.

“I feel absolutely dreadful about this,” he said. He added that he “may have been a bit low-key” about insisting she came back to see him for the last ECG results because he did not want to compound her stress – a key trigger to palpitations, although she had denied being stressed, he said.

He told acting Bradford coroner Professor Paul Marks a new computerised system had now been implemented alerting GPs if patients needing referrals did not get back in touch.

Post-mortem tests showed Mrs Stewart’s heart had extensive scarring which could have developed over the years from a congenital heart disease.

The inquest heard if Mrs Stewart had been referred she could have gone on to have a specialist pacemaker fitted.

Professor Marks said he was satisfiedsteps had been taken by the surgery to address the system failure.

Recording a verdict of death from natural causes, he told the family it did not deny them the right to seek alternative redress in another legal forum.