Ambulance crews were carrying medicine which could person saved Dawn Sturgess' life, an autarkic enquiry into her decease was told.
Ms Sturgess, 44, was inadvertently exposed to the deadly nervus cause Novichok successful Amesbury successful June 2018.
Medicine DuoDate, which is an antidote to nervus cause poisoning, had been introduced connected each exigency vehicles the twelvemonth anterior to her death.
However, paramedics initially misdiagnosed the mother-of-three with opiate-poisoning owed to an overlap of symptoms, including respiratory issues and fading consciousness.
By the clip her spouse Charlie Rowley go sick aboriginal that afternoon, paramedics raised concerns this could beryllium nervus cause poisoning, but were efficaciously “overruled” by Wiltshire Police, the proceeding was told.
Wayne Darch, who was caput of exigency operations astatine the South Western Ambulance Service successful 2018, told the enquiry much "could person done" to bid unit connected "misdiagnosis awareness".
It is understood the nervus cause had been hidden wrong a decorator perfume bottle, which Ms Sturgess’ spouse unknowingly gave to her.
Lead counsel Andrew O’Connor KC told the enquiry she suffered from bosom nonaccomplishment due to the fact that of the Novichok poison.
In the end, helium adds, the encephalon wounded Ms Sturgess sustained from a deficiency of oxygen during the archetypal play was the "immediate cause" of her death.
The overriding question posed by Mr O’Connor astatine the enquiry is: “Was the poisoning of Dawn Sturgess preventable?”
Mr Darch told the enquiry that poisoning from organophosphates, a toxic chemic compound, tin travel from respective sources including pesticides, fertiliser, and flammable retardants.
He added: “A fig of our clinicians volition spell a full vocation without witnessing oregon attending an organophosphate oregon nervus cause poisoning, whether accidental oregon deliberate.
“We responded to the symptoms that we believed were of an opiate overdose nature. It was immoderate hours aboriginal that it became known this was not an opiate-related incident.
“My position is that astatine the clip we did the champion we could with what we had disposable to us.”
This misdiagnosis meant the DuoDate attraction was not administered, which could person prevented Ms Sturgess' death, the enquiry heard.
Just 4 months anterior to Ms Sturgess' death, erstwhile Russian spy Sergei Skripal and his girl Yulia Skripal had been poisoned with the aforesaid nervus agent, astir 8 miles distant successful Salisbury.
The brace had gone for luncheon astatine a pub earlier they were both recovered collapsed "in a superior condition" connected a buying centre bench.
A study astatine the clip stated ambulance unit had likewise misdiagnosed the pair, and the existent origin of their unwellness was not revealed until "15 hours later".
Fortunately, some made a afloat betterment and are presently surviving nether protection.
Michael Mansfield KC, representing the household of Dawn Sturgess, asked Mr Darch what provisions had been made to support the nationalist pursuing this archetypal onslaught successful March.
Local exigency workers look not to person been warned to look retired for the information that symptoms betwixt cause overdoses and nervus cause poisonings tin beryllium easy confused - meaning it was not connected their contiguous radar erstwhile Ms Sturgess fell ill.
Mr Mansfield besides referenced an interior papers sent by the Department of Health and Social Care 10 days aft the Salisbury poisonings, titled 'Risk of Secondary Incident'.
It contained a database of the worst-case scenarios, 1 of which was deemed the ‘accidental find of a discarded agent’ elsewhere.
However, the missive was advised "not to beryllium forwarded further than necessary", and Mr Darch alleges helium ne'er saw it.
“One of the problems aft the Salisbury onslaught was a mindset," Mr Mansfield said.
"That's due to the fact that Novichok oregon nervus cause poisoning was uncommon oregon virtually unknown, that it wouldn’t hap again.”
Mr Darch said helium was responding connected the proposal of Public Health experts astatine the clip that the "risk was highly low".
BBC newsman Dan O'Brien has been pursuing this morning’s session.
He said: "The large taxable has been astir connection – oregon possibly the deficiency of it – betwixt antithetic organisations progressive successful the effect to the Salisbury and Amesbury Novichok incidents.
"By the clip Charlie had go sick aboriginal that afternoon, the paramedics raised concerns this could really beryllium a nervus cause – but were efficaciously “overruled” by Wiltshire Police.
"Police were past instructed to hunt Charlie’s level – contempt that informing from medics connected the ground, and contempt 1 of their ain officers becoming critically unwell aft searching the Skripal location 4 months earlier," helium added.