Grieving WA parents welcome coronial inquest findings into daughter's death

Kim and Kellie Hunter pushed for an inquest into the 2019 death of their daughter Ashleigh Hunter.

Ashleigh died at Royal Perth Hospital after the signs of sepsis were missed when she went in with meningococcal.

The 26-year-old arrived by ambulance and despite telling the triage nurse her pain was 10 out of 10, she wasn't triaged as a priority.

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The emergency department was overcrowded and Ashleigh was ramped outside, thrashing around in pain on a stretcher for an hour before she was finally seen by a doctor.

"She was outside the ED, they couldn't address the pain management because of hospital rules and so she died a very painful death," dad Kim told 9News.

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"Extremely traumatic and manifestly inhumane and it's not something that we should ever accept in a first world country like Australia," mum Kellie told 9News.

State Coroner Ros Fogliani found there were missed opportunities to escalate her care.

She also found Ashleigh's admission of drug taking the night before clouded the clinicians' consideration of sepsis.

"The quality of the care and treatment afforded to Ashleigh was below the standard that ought to be expected of a public hospital in Western Australia," Fogliani said in the findings.

"I don't think any individuals set out to cause our daughter any particular harm that day - it's just the broken system we work within," Kellie said.

"We live with the idea that she was never given every chance to survive. We live with 'what ifs'."

WA Health Minister Amber-Jade Sanderson said almost half $500 million had since been spent on improving access to emergency care, sparking a recent reduction in ambulance ramping.