The man's GP had telephoned the Royal Hampshire County Hospital, Winchester, saying he believed his patient had an infected shoulder and was being sent in by ambulance. But the message was not passed on to the duty doctor, and the patient, Jim Anderson, 57, from Andover, Hampshire, was sent home without any antibiotics.
Carol Anderson, his widow, told the hearing in Winchester that her husband had gone to bed. 'Later I went to see him and pulled back the bed covers. I could see he was bleeding under the skin on his shoulder and it was moving up his neck.'
Mrs Anderson phoned Dr Hamilton, her GP, who told her to call an ambulance. Dr Hamilton told the inquest: 'It sounded extremely serious from her description and I thought he should go back to hospital immediately.'
Dr Hamilton said he had sent Mr Anderson to hospital earlier because he suspected he had developed an infection in his right shoulder, which was painful and swollen, after grazing his arm five days earlier in an accident.
But when Mr Anderson arrived at the hospital the duty doctor, Dr Malcolm Lawrence, had not been told of Dr Hamilton's message or his diagnosis. Dr Lawrence, who works in the orthopaedic department, examined Mr Anderson and decided he was probably suffering from a frozen shoulder.
Dr Lawrence told the inquest: 'I did not believe antibiotics were appropriate because I did not think there was an infection.' He was unable to explain to the coroner why he was not given details of Dr Hamilton's medical opinion.
The inquest was told that when Mr Anderson was admitted to hospital for the second time later that night, it was too late to save his life. Dr Matthew Dryden, a consultant microbiologist, said the infection had been caused by Streptococcus A, which can cause necrotising fasciitis, a type of gangrene in which skin, muscle and fat cells liquefy and die.
Dr David Hewett, assistant medical director at the hospital, said last night that Dr Lawrence had gone through the same medical procedures as he would have done had the message been passed on. There had been no sign of an infection when Mr Anderson was admitted.
The coroner, Grahame Short, recorded a verdict of accidental death.