Ms Boothby-O’Neill had been admitted three times to the Royal Devon and Exeter Hospital but was discharged each time and sent home, the inquest was told. Ms Boothby-O’Neill’s mother, Sarah Boothby, wrote to the GP practice manager in the April wanting to know what had "gone badly wrong" with the care of her daughter. "Since 10 March, 2021, I have been the only person providing care for a person unable to sit, stand or chew," she wrote. "You did not call as arranged then and when I rang the surgery, they told me you were off sick. "Illness stopped them knowing her better, but they knew her love and on her death bed she remembered them."