A grieving Spearwood mother wants an independent inquiry into the death of her daughter from a suspected blood clot two weeks after she was sent home from hospital after bungled care.
One year on, Jackie Zele says she does not want another family to go through the anguish of losing a loved one from of a series of fatal oversights.
She wants to raise awareness that even seemingly healthy young people can suffer pulmonary hypertension, a form of high blood pressure in the arteries of the lungs sometimes linked to blood clots.
Her daughter Petra, 28, died at Fremantle Hospital last May, two weeks after being sent home from its emergency department with painkillers to treat what doctors said was likely be a sore muscle.
Ms Zele, who had a science degree and worked as a sustainability officer with Cottesloe Town Council, was an avid dancer who had never been unwell.
She had married the love of her life, Petros, who she met in Greece, only four months earlier.
She went to hospital on May 9 with breathlessness and pain in her lower left side near her chest.
Doctors performed an electrocardiogram, which records electrical activity of the heart, but the family believes it was not correctly interpreted and acted on.
The hospital later admitted the ECG was not normal and that it failed to label it or record the results in her discharge letter.
Mrs Zele believes that, by not acting on the test results, the hospital sealed her eldest daughter's fate.
More events were to come that would see her slip through the cracks again. When she became short of breath again two weeks later, she went to her family GP who sent her to a cardiologist for an echocardiogram, or ultrasound of the heart. In a breakdown of communication between the GP and cardiologist, the results of that test, which showed severe pulmonary hypertension needing attention, were not relayed to Ms Zele.
The next day, she collapsed and was rushed to hospital where doctors spent an hour resuscitating her. She went into a coma and died in hospital a few days later.
Five months after her death, her stunned family finally sought answers from the hospital.
"We wanted to know why this happened to someone so active and full of life," Mrs Zele said. "She was a beautiful, fit and healthy young girl."
An apology from David Blythe, acting director of clinical services at the hospital, admitted the diagnosis on May 9 was wrong.
"On behalf of the hospital I acknowledge that the assessment that she had musculoskeletal pain was an error and I apologise unreservedly," he wrote in a letter four months ago.
Dr Blythe admitted the ECG "was not normal". "Petra had symptoms which were consistent, although not specific for, pulmonary embolism," he said. "There was no label on the ECG performed in the emergency department. This is an oversight on our part. There is no mention of the ECG in the discharge letter and no results recorded."
Dr Blythe said the doctor who saw Ms Zele on May 9 would receive counselling and education.
He said according to hospital notes, Ms Zele was not on any medication that could increase the risk of clots but he now understood she had been taking the contraceptive pill. But Mrs Zele maintains the pill was not on her daughter's notes because she was never asked.
The family has been told the case will be investigated by the Health Department's sentinel events program and has been referred to the Coroner's office.
A spokeswoman for lawyers Julian Johnson confirmed the firm was also investigating the events leading up to the death.
Mrs Zele, who has joined a support group, the WA Pulmonary Hypertension Association, says she wants to ensure there are no more tragedies.
"Nothing's going to bring back Petra but we believe her death was preventable and we don't want others to go through a similar tragedy," she said. "We trust doctors to look after us and I don't want to point the finger of blame. But we still don't have all the answers and we need to know there will be changes."
A Fremantle Hospital spokeswoman confirmed the incident had been investigated under the sentinel event program and referred to the Coroner.