A doctors' surgery has been sharply criticised for "lost opportunities" to help a patient who phoned five times before getting a visit.
Ann Swift, 75, was found dead at her Cinderhill home after being seen by a nurse from the Strelley Health Centre.
That visit came 11 hours after Mrs Swift first called, an inquest heard. She had chronic obstructive pulmonary disease and heart problems. She died of pneumonia.
Assistant Coroner Dr Elizabeth Didcock returned a narrative conclusion on Mrs Swift, who died on January 4 after making calls the previous day.
The coroner said she was concerned that the GP practice did not carry out a detailed investigation into the death until the Care Quality Commission became involved.
"I have no confidence that changes to home visits policy will necessarily lead to sufficient changes," said the coroner. She felt that the practice failed to log all calls properly.
She said that the nurse "underestimated the severity" of Mrs Swift's condition and failed to suggest sending her to hospital.
"This was a missed opportunity to arrange appropriate medical care but it is not possible to say whether or not she would have survived," the coroner said.
The coroner referred to an "unsafe triage" procedure and home visits, questioning the view of practice manager Dr Marcus Bicknell that it was "rather unusual" in this case.
The coroner said the problem was "regular and systemic rather than unusual."
She said that nurse Denise Nath would have been helped by having more details of Mrs Swift's medical history.
Mrs Swift told her that she had been "unwell for 24 hours and became more breathless," the inquest had been told.
A neighbour said she had been "slumped over sideways, holding the door frame," and seemed to be finding it "hard to talk."
She was sitting down when seen by the nurse and the coroner said this was "an opportunity lost in getting the overall picture."
Checks on Mrs Swift's phone showed that she contacted the health centre five times, starting at 8.16am and making the last call just before 6pm. Not all the calls were logged by staff.
Mrs Swift was said to have had "more energy over Christmas" but had complained of feeling ill since New Year's Eve.
Mrs Swift's daughter Julie had told the inquest: "I had spoken to her on the phone the evening before after the nurse had visited. She sounded frail, fragile and exhausted. She was speaking very slowly.
"She said she felt dreadful. I was surprised she hadn't been admitted to hospital. She said she had antibiotics and she had taken the first lot."
Nottinghamshire Live reported in June that Strelley Health Centre had been closed down by Care Quality Commission inspectors.
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