A coroner has called on the Prime Minister to press ahead with a public inquiry into the pandemic “as soon as practicable” after concluding that it is unclear how a heavily pregnant nurse contracted coronavirus.

Coroner Emma Whitting delivered a narrative conclusion at the inquest into the death of sister Mary Agyapong, 28, who died last year at the Luton and Dunstable Hospital where she worked, five days after giving birth to her second child.

She spent the last week of her life with coronavirus, a diagnosis initially dismissed by medics at the hospital where she worked, despite collapsing at home and suffering acute breathing difficulties.

In closing the inquest at Bedfordshire and Luton Coroner’s Court, the coroner said: “I would like to express my own condolences to Mary’s family.

“Whilst Mary’s untimely death is first and foremost a tragedy for you her husband, for her children, and all her relations, colleagues and friends, it is for society too.

“As a society, it is important that we learn from all of the lives that have been lost as a result of this terrible pandemic and to consider the wider policy implications that may arise from each and every one of these.

“Since this is a process which goes far beyond a coroner’s inquest and the Prime Minister has indicated his intention to hold a full public inquiry into the Covid-19 pandemic, I urge him to proceed with this as soon as practicable.”

Earlier this month, Mr Johnson said he remains committed to an inquiry in the future, but that holding one now would be an “irresponsible diversion” as officials need to concentrate their “energies” on combatting the pandemic.

Labour leader Sir Keir Starmer has demanded a “full public inquiry” into the handling of the pandemic “as soon as restrictions lift” in order to “get to the bottom of the many mistakes made” during the outbreak.

The inquest began last week on the day the nation marked a national day of reflection for those who had died in the pandemic.

Stating that Ms Agyapong died of of multiple organ failure and Covid-19, the coroner said: “The deceased died after contracting Covid-19 but it remains unclear where and when her exposure to the virus had occurred.”

Ms Agyapong’s widower Ernest Boateng, had told the inquest that she was concerned about becoming infected at work while heavily pregnant.

Luton-based Ms Agyapong, who was originally from Ghana, died as the Covid-19 case rate soared across the UK.

After the ruling Mr Boateng said: “The sudden death of my wife and the mother of our two children has been the hardest pain to bear. In those early days after Mary’s death, I was only able to carry on because of the need to care for our children and provide them with a loving home.

“Mary was strong, capable, vibrant, full of life and the most precious person in my life. It is still difficult to believe that she lost her life to the Covid-19 virus.

“I am glad that those who were involved in Mary’s care in the final weeks of her life have had to give a full account of what happened.

“I hope that the fact that they have had to do so will remind them of the need to always give the best possible care to women in Mary’s situation – especially black women who are themselves on the frontline of healthcare.”

Ms Agyapong was admitted to hospital with breathing difficulties on April 5, but was discharged later that day – something she was unhappy with – and was readmitted two days later with coronavirus symptoms, at 35 weeks pregnant.

Surgeons safely delivered the baby, also named Mary, by Caesarean section before Ms Agyapong was transferred to the intensive care unit on April 8.

Ms Agyapong’s condition did not improve and by the following morning she needed increasing levels of oxygen.

She was showing signs of severe Covid-19 pneumonia which was later confirmed by a chest x-ray.

Her condition worsened and in the early hours of April 12 she was diagnosed with a cytokine storm, a common complication of Covid-19.

The coroner said: “Despite all efforts to treat her, she suffered a cardiac arrest later that morning and her death was confirmed at 10.30 hours.”

Mr Boateng had told the inquest that his wife “was very concerned about the situation involving Covid-19”, and would immediately shower after coming home from work, and  sleep in their spare room to protect her husband and young son.

Mr Boateng had said he strongly believed his wife contracted coronavirus while at work, and also questioned why she was discharged from hospital on April 5 with a course of antibiotics, despite having coronavirus symptoms.

Dr William Manning, who decided to discharge Ms Agyapong on her initial admission to hospital, told the inquest he “suspected she had Covid-19”, but sent her home because she did not require oxygen.

Dr Manning added: “She didn’t seem particularly happy to go home.”

Other medical staff told the coroner they were satisfied with the care provided to Ms Agyapong, and said her condition deteriorated rapidly.

Dr Deborah Shaw, an intensive care consultant who saw Ms Agyapong the day after she gave birth, said: “I was very happy with the level of care she was getting.”

Dr Muhammad Peerbhoy, a consultant physician who saw the patient the same day, added: “In my opinion, I think the treatment was proportionate.”

After the hearing Bedfordshire Hospitals NHS Foundation Trust chief executive David Carter described Ms Agyapong as “a highly valued and loved member of our team and a fantastic nurse”.

He said: “We are reassured that the coroner has found no areas of concern regarding our support for, or care of Mary, and I would like to pay tribute to our staff who did everything they could for Mary in hugely challenging circumstances.”