A "kind and loving" 27-year-old man died from a blood clot two weeks after spraining his ankle.
An inquest heard Callum Jones' condition may have been found if he had had a face-to-face consultation with a doctor - instead of a telephone one - who would have seen his ankle in a plastic "moon boot".
Callum had been with his family walking their dogs at Loggerhead, Denbighshire on October 3, 2021 when he slipped on a wooden footbridge and hurt his right ankle.
Callum went to Holywell Community Hospital and then Ysbyty Glan Clwyd, where he was diagnosed with a fractured ankle. He was given a protective boot and crutches.On October 11 he went back for an appointment at Ysbyty Glan Clwyd where the diagnosis was changed to badly-sprained ligaments and tendons. But two days later he became breathless and had pains in his shoulder and chest, the coroner heard.
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On October 15 he rang Shotton Lane surgery for a telephone consultation. Dr Chris Murphy, his GP, said that during their nine-minute conversation he diagnosed "pleuritic pain" from pleurisy. Dr Murphy told the coroner he was not aware Callum was wearing an ankle boot.
Callum collapsed at home in Ewloe on October 17 and was taken to the Countess of Chester Hospital, but despite the best efforts of medics could not be saved and died early the next day.
A post-mortem examination found Callum died from a pulmonary embolism as a result of immobility caused by the sprained ligament.
Dr Murphy told the coroner he had been in "complete shock" when he learned Callum had died.
The coroner asked Dr Murphy whether, if he had seen the protective boot in a face to face meeting, he would have considered an alternative diagnosis to pleurisy. Dr Murphy agreed he would.
The GP said there are now "a lot more face to face appointments in the afternoon" but it is still a pre-eminently telephone triage service.
The inquest also heard Callum's discharge letter from Ysbyty Glan Clwyd only arrived at the GP surgery a "couple of weeks" after his death. The GP said: "The communication between primary and secondary care is a constant thorn in our side."
The coroner John Gittins concluded that the death was due to an accident. But said he will contact Betsi Cadwaladr University Health Board to explain how long it takes for discharge letters to be sent out.
He said: "I am concerned when Dr Murphy says it's not unusual when it's some weeks after when we have the discharge letter. I will be asking the health board to report to me in three weeks to explain the length of time it takes currently for discharge letters (to be sent out)."
He said if he finds at this point that the time frame represents a risk to other patients he said he would then be obliged to make a Regulation 28 ruling to prevent future deaths.
'A gentle boy, kind and loving'
Callum has been described as a "gentle boy, kind and loving" by his mother, Kim Jones. He had been a deputy retail manager at the Card Factory shop in Broughton retail park. The coroner noted that after his death there had been an outpouring of love and support.After the hearing, Mrs Jones said she believed her son "could have been saved if he had been seen (by his GP) in person."