A coroner has concluded a Derbyshire man who 'felt let down by the medical system' died of natural causes.
Last month, a Chesterfield coroners' court inquest heard Jeremy Mellor passed away in his home on Springfield Rise, Matlock, on New Year's Eve in 2016.
He was 41.
A post-mortem report revealed Mr Mellor died of sepsis which was caused by a perforated small bowel.
Concluding his inquest today, coroner Kathryn Hayes said: “On December 31, 2016, Mr Mellor collapsed and died at home from sepsis due to a perforated and ischaemic small bowel.
“This was an unusual presentation of an extremely unusual illness which may well have been fatal even with the best medical care.
“There were no causative failings in his medical care although on December 24, 2016, there was no senior review of his condition and documentation was not fully completed.”
Ms Hayes concluded Mr Mellor died of natural causes.
The court previously heard Mr Mellor attended the accident and emergency department at Chesterfield Royal Hospital on three occasions in the four months before he died and complained of abdominal pain on each visit.
Dr Jern Yeoh said he saw Mr Mellor on August 21, 2016, and noted he had a high white blood cell count.
A high white blood cell count may indicate that a person has an infection in their body.
Mr Mellor later discharged himself from the hospital after a normal CT scan, the court heard.
Dr Fahima Shakir said Mr Mellor's 'observations were normal' when she examined him on December 5, 2016, but found he had a raised white blood cell count.
She added she wrote to Mr Mellor's GP advising further investigations into his abdominal pain on an out-patient basis.
Dr Osarugue Esenamunjor told the inquest she had only been working in the accident and emergency department for two weeks when Mr Mellor came in for the final time on Christmas Eve, 2016.
According to Dr Esenamunjor, he had a 'very high' white blood cell count.
She said she 'must have' discussed this with a senior doctor although she could not remember their name.
Mr Mellor was subsequently discharged.
His sister Michelle Mellor asked Dr Esenamunjor: "Why wasn't he kept in? Why wasn't he offered further investigations?"
She replied: "In hindsight, it should have happened."
Dr Katherine Lendrum conducted an independent investigation following Mr Mellor's death.
Referring to December 5, Dr Lendrum said she 'probably would have sent him home' like Dr Shakir did.
"I don't think I would have done anything differently," she added.
But referring to Christmas Eve, Dr Lendrum described Mr Mellor's white blood cell count as 'grossly abnormal'.
She said: "On balance, I would have wanted to arrange admission for further investigations to review the blood results."
But she added: "Whether those tests would have helped solve what was wrong with Mr Mellor, we don't know."
Dr Lendrum told how a number of lessons had been learned and changes implemented following Mr Mellor's death.
She said that Dr Esenamunjor had 'thought very hard about what happened and what she'd do differently'.
She added: "She was a junior in a challenging environment - especially around Christmas.
"There are countless distractions."
Mr Mellor's partner Karen Laing said he 'didn't have any faith in the medical system at all' and 'he felt let down by the medical system'.
"He wanted answers - nobody gave him any answers," she added.
Ms Laing described Mr Mellor as 'so happy-go-lucky'.
She said she wanted to raise awareness about sepsis, which kills 44,000 people a year in Britain.
Ms Hayes added: "It's something which can happen extremely quickly and have devastating consequences.
"It can be very difficult to see the signs."
Visit www.nhs.uk/conditions/sepsis for more information about sepsis.