A previously “fit and healthy” teenager died from the effects of glandular fever three days after a failed attempt to see a GP, a coroner has said.
Toby Hudson’s Weymouth surgery had “phone problems” and the 19-year-old was seen two days later at an NHS walk-in centre, the inquest heard.
However, Dorset Coroner Rachael Griffin said no NHS fault led to his death from a ruptured spleen and sepsis in 2019.
She recorded a conclusion of death by natural causes.
Mr Hudson, who was suffering from a sore throat, was unable to contact the GP surgery for a day because of the phone system problems, the hearing was told.
When he got through on 2 July 2019, he was told he could not be seen immediately because his GP registration had been transferred to his university city of Southampton.
His brother took him to an NHS walk-in centre the following day, where he was wrongly diagnosed with tonsillitis and given antibiotics, the inquest heard.
The following day, an ambulance was called when his condition deteriorated.
Paramedics called for help from a back-up crew which was wrongly sent to the family home rather than to the road where the ambulance had stopped for resuscitation attempts, the hearing was told.
The paramedics also wrongly inserted an intubation tube.
Dr Phil Cowburn, acute medical director at South Western Ambulance Service, told the inquest: “Unfortunately I think Toby suffered such a catastrophic event that even with a deployment of more resources it would have not made a difference to the outcome.”
Ms Griffin said the “fit, healthy, bright and popular teenager” died in hospital more than two hours later.
However, she said she was satisfied that medical issues raised during the inquest did not contribute to or cause the death.
The coroner said she would not send a Report to Prevent Future Deaths to the ambulance trust because it had already agreed to make improvements.
Expressing her condolences to the teenager’s family, she said his loss was “an extremely tragic and rare event”.