Coroner John Cannon was speaking after the death of a 21 year old man who died at the side of a road just minutes after being treated at a medical centre.
Martin McLaughlin was sent home after being treated for severe stomach pain and given four Kapake painkillers.
Mr. McLaughlin, of Glengad, Inishowen attended the out-of-hours GP service NowDoc on February 14th 2009.
He was brought to the medical centre in Carndonagh by his aunt Mary Doherty suffering from severe abdominal pains.
He arrived at 5.48pm but was left waiting for 56 minutes until being attended to by Dr Andreas Bernhard at 6.45pm.
Dr Bernard told Buncrana Coroner’s Court that he checked Mr McLaughlin for various symptoms.
He said his blood pressure and temperature was normal but that he was complaining about an “on and off’ tenderness in his stomach.
Dr Bernard, who is originally from South Africa but has been a GP in Ireland since 2007, said he had no reason to admit Mr McLaughlin to hospital and released him.
However a few minutes later at Dr.Bernard received an emergency call at 7.25pm and travelled to Glengad Cottages where he found Mr McLaughlin on the ground at 7.40pm.
Despite administering CPR for almost 20 minutes, Mr McLaughlin was pronounced dead at 8pm.
Barrister for the McLaughlin family, Peter Nolan asked Dr Berhnard if he was aware that the late Mr McLaughlin suffered from Ehlers-Danlos syndrome?
Dr Berhnard said he was not despite the fact that he had first-hand experience of treating a patient with it in Capetown, South Africa where he had qualified as a doctor in 1979.
Mr Nolan said he found it extraordinary that he could not tell from the condition of Mr McLaughlin that he was suffering from such a syndrome.
“I find it extraordinary that you could not tell he was suffering from this syndrome considering his facial features and also that you did not write down the actual family history`” he said.
However Dr Berhnard said the syndrome took many forms and also that he did not have the time to go into full family medical history.
Coroner John Cannon returned a verdict of medical misadventure and agreed with pathologist Kartina Dillon that he died as a result of a thorn aorta and also Ehlers-Danlos.
However he said there now needs to be a full examination of how the Nowdoc service access computer records.
“There is a glaring inadequacy. The fact that the computer medical history of a patient is shut down and is inaccessible for NowDoc from examining patients records after hours is incredible in this day and age,” he said.
He also added that the triage system whereby patients are currently assessed by non-medic al personnel when they walk in to a medical centre out of hours also needs to be reviewed.
The late Mr McLaughlin’s mother Mrs Kathleen McLaughlin said she was just relieved her ordeal was now over.
“We’re just happy it’s all over. We feel a weight has been lifted off our shoulder,” she said.