'SIGNIFICANT failures' were made by a Barnsley GP whose patient died days after having a heart attack.
Coroner Chris Dorries said the failures meant Gary Newsome's condition wasn't diagnosed at a time when his life was likely to be saved by hospital treatment.
An inquest ruled Dr John Harban, a GP of 23 years' experience, had made failures during a consultation with Gary days before his death.
Gary, 50, who was overweight, smoked and suffered from diabetes, allegedly told the doctor he was suffering from chest pains.
The coroner said there was insufficiency both of enquiry of the patient and of examining him during the consultation.
In particular, he said there was no questioning as to whether the shortness of breath was accompanied by chest pain.
Mr Dorries said he realised Gary was a patient with 'very high risk factors' for coronary disease and this was his first presentation of shortness of breath.
"I would wish to make clear that I do not doubt that Dr Harban was seeking to do his best for Mr Newsome on July 15, 2011, but the clear evidence of the experts was that important things were not done that should have been done.
"On the basis of expert evidence there were significant failures during this consultation. In consequence Mr Newsome's condition wasn't diagnosed at a time when his life was likely to be saved by hospital treatment."
Gary, of Hartington Drive, Honeywell, had been to see Dr Harban, who works at Lundwood Medical Centre and went into the consultation room with his brother Allan, who said Gary was complaining of chest pains and being out of breath.
Dr Harban said he thought his patient was starting with a viral illness, and a developing condition, an obstruction of the airways from the amount of cigarettes he was smoking.
He said he examined Gary on what he was told and sent him home without any treatment.
He was found dead at home on July 19.
The cause of death was a heart attack which had happened between three and seven days prior to his death.
The inquest also revealed how notes were backdated following a telephone consultation with Gary on Monday July 18.
Gary had phoned the surgery on July 18 and a note was made by the receptionist saying he couldn't breathe and had had chest pains since last Thursday.
Mr Dorries said he intends to advise NHS England of the issues surrounding note keeping for the consultations.
Gary's sister, Janet Asquith said Gary's death has 'cut the family to the core'.
Janet says she wants Dr Harban struck off and says the family is complaining to the General Medical Council.
A spokesman for the Medical Defence Union said Dr Harban could not comment due to patient confidentiality.