A grieving mum received an answerphone message recording her daughter's dying moments – after she found her lifeless body clutching the phone.
Evelyn Purchase, 20, died from pneumonia hours after she was misdiagnosed by a doctor and sent home with anti-depressants and a repeat prescription for antibiotics.
She desperately tried to call her mother, Tara, as she lay dying but Mrs Purchase returned to her home in Halesowen, West Midlands, on her birthday to find her body.
Now, a coroner has ruled that Evelyn's doctor performed a 'substandard' examination on her – and made a number of assumptions about her condition.
Mrs Purchase said: "Evelyn was still poorly the day after her trip to the doctor, which was my birthday, and she decided to stay at home while I went out with her sister, Dana.
"We came home and I went to check on Evelyn, and found her lifeless in her bedroom, clutching the phone. My heart broke in two and I will never get over it.
"I later realised I had a voicemail message and when I listened to it, I realised that Evelyn had tried to call me and I could hear her dying in the message.
"She has left a huge hole in all of our lives, and we will never get over her death.
"I will never be able to forgive myself for not being there for her when she needed me. I wish someone had told us how ill she was.
"We begged the doctor to send her for a chest X-ray, but he wouldn't."
Evelyn visited Dr Mahmud Ahmed at a walk in centre in Dudley, West Midlands, in April 2013, with her mother, complaining that she felt unwell.
The doctor, who had previously treated Evelyn, prescribed her with antibiotics, but didn't realise he had previously given her two courses of antibiotics which failed to treat her worsening condition.
An inquest heard that he had diagnosed her with a chest infection – and put her lack of appetite down to her being depressed, despite not conducting a mental health examination.
And just 36 hours after she saw the doctor, Evelyn died as a result of her untreated pneumonia.
Coroner Robin Balmain said that the doctor's examination was substandard and that he made a number of assumptions when prescribing her with a further course of antibiotics – although ruled that her death was due to by natural causes.
He ruled that it would be impossible to say whether a correct diagnosis would have prevented her death.
Mrs Purchase said after the inquest that she now plans to bring the case before the General Medical Council and get justice for her daughter.