A coroner said there was a "risk future deaths could occur" unless action was taken after a man with sepsis died after a GP's calls to a hospital went unanswered.
Terrence Frost died of natural causes on 17 July 2024 at Ipswich Hospital, in Suffolk, after he collapsed and suffered a cardiac arrest.
The 84-year-old had gone in with a serious infection or inflammation following advice from his GP, who tried to contact the hospital ahead of his arrival to no avail.
Nigel Parsley, senior coroner for Suffolk, said the doctor's "inability to promptly communicate" with its medical assessment unit or A&E department was a concern.
In a Prevention of Future Deaths report, he said: "[That] could lead to future deaths where suspected sepsis or other life-threatening conditions have been differentially diagnosed, especially if those conditions have progressed further than Terrence's had at the time of his arrival.
"I am further concerned that evidence was heard from a clinician based at the Ipswich Hospital itself, that they too found contacting the medical assessment unit extremely difficult, with internal hospital telephone calls frequently going unanswered."
Source: BBC News, 16 March 2026
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