But Zafar Siddique, coroner for the Black Country, said he would be writing to the trust that runs Russells Hall Hospital, Dudley, with his concerns over Natalie Billingham’s death.
The mother-of-six was suffering with "flesh-eating disease" necrotizing fasciitis and sepsis – but hospital doctors failed to diagnose it until her condition rapidly deteriorated hours after she was admitted to Russell’s Hall, it was heard.
An inquest was told Mrs Billingham died after she was originally admitted to A&E on February 28 with suspected deep vein thrombosis (DVT).
Her family told how she had spent 12 hours in a cubicle.
Black Country Coroner’s Court heard how the 33-year-old underwent surgery three times, during which her leg was amputated, but her family were later told the infection had spread too far and caused organ failure.
She died on March 2. A cause of death was listed as multiple organ failure.
Yesterday Mr Siddique recorded a narrative conclusion into her death but said he couldn’t contribute neglect as part of his conclusion.
He said: “She was admitted having previously been discharged from Sandwell Hospital with an injury to her right foot.
"She was suffering significant pain in her foot, a d-dimer test was positive, a working diagnosis of DVT was made.
"No treatment was commenced, a national early warning score was miscalculated and there was a delay in starting pathway for sepsis.
“She underwent emergency surgery. She had been diagnosed with necrotizing fasciitis. Despite surgery, she passed away on March 2, at 6.50pm.
"I don’t make neglect a contribution in my narrative conclusion. I can’t say there was a direct cause or link.”
Mr Siddique said he would still be writing a report to the Dudley Group NHS Foundation Trust with his concerns.
“On balance, I still have concerns about the progress being made at the trust and other deaths being prevented," he said.
"I offer my deepest condolences to the family.
"She was a young mother with very young children and I can't imagine the pain you are all going through."