Percy Mullaly, aged 77, died at his home in Newhall Gardens, Shrewsbury, on August 22, 2020, from a blood clot on the lungs, with heart disease being a contributory factor, an inquest on November 22 heard.
Assistant Shropshire and Telford & Wrekin coroner Heath Westerman took some time to consider his findings, emailing his conclusions to the family last week.
The inquest had heard that two doctors at the Claremont Surgery in Shrewsbury accepted that they had missed red flag clues in telephone calls on August 19 and August 20.
Dr Mary Eardley accepted in evidence that she did not adequately explore those symptoms further which were red flag symptoms of a further pulmonary embolism/deep vein thrombosis.
Mr Mullaly said that he could hardly breathe during the conversation; could hardly walk 10 yards without being totally breathless and had chest pain.
She accepted that is was a missed opportunity to explore them further and either arrange for an immediate face-to-face consultation or refer to hospital admission via accident and emergency.
Dr Michael Fallon, also a GP at Claremont Surgery, spoke with Mr Mullaly on August 19.
In a recording of the phone call played in court Mr Mullaly informed Dr Fallon that he suspected that his symptoms might be a recurrence of deep vein thrombosis going to his lungs.
Dr Fallon accepted in evidence that it was a missed opportunity to verbally explore the symptoms that Mr Mullaly was expressing; to expedite a chest X-ray and to ask Mr Mullaly to come into the practice straight away for a face-to-face consultation.
Mr Westerman said that even if Dr Fallon and Dr Eardley had taken further action on August 19 and 20 it was impossible to confirm the prognosis for survival and therefore although they were missed opportunities it cannot be said to have caused or contributed to his death.
Mr Westerman also decided not to issue a Regulation 28 Report to prevent future deaths.
Mr Mullaly's son, Darren, said he was "disappointed with the verdict but only because there was insufficient evidence to prove that my dad’s death was either preventable or not preventable and was therefore expecting an open verdict".
He said: "It also seems ironic that this evidence was not available because doctors did not initiate the urgent assessment and physical examination, which they both agree should have been done. I completely understand, however, that if the burden of proof was on preventability, that this was the only real viable outcome.
"My frustration and devastation remains focused around the loss of my dad and the standard of care afforded to him by the two doctors in the days leading up to his death.
"Both doctors have accepted that they ‘missed opportunities’ and this was documented in the narrative report of the verdict."
He added: "Both doctors reported that they had not realised the deterioration in my dad’s health but that is not surprising as they failed to ask a single question about it.
"I now have to accept this verdict and me and the rest of dad’s family will now try to find ways to live without him being here.
"He was a huge character, loved and respected by so many.
"He had a huge positive influence on thousands of children across the county over his 40 years of teaching and later on through his role as chairman of the Shropshire Schools and Colleges FA. Wherever I go, somebody always asks if I am related to Percy and I say proudly 'Yes, I’m his son'.
"It has left an incredible void in all of our lives."