A 19-year-old died from sepsis after trying 25 times to get through to a GP surgery only to be refused an appointment, an inquest heard.
University student Toby Hudson was unable to speak to anyone at the practice because of a faulty phone system and eventually gave up and called again the next day to be told he could not be seen for at least 48 hours.
The tragic teenager was told that due to him being registered at another surgery in his university town of Southampton, Hants, he could either wait two days to re-register or go to an urgent care walk-in centre.
Toby died two days after he had first sought help at the Wyke Regis & Lanehouse Medical Practice in Weymouth, Dorset.
An inquest into his death in Bournemouth heard Toby had previously been a patient at the Weymouth practice.
However, when he moved to Southampton to study chemistry at university he registered at a new clinic closer to campus.
He had been suffering from a cough for around two months before he returned to his family home in Weymouth in the summer of 2019.
Toby was suffering from swollen glands and 'puffy' tonsils and a sore throat when his parents told him to speak to a GP.
He attended the centre and was seen by nurse practitioner who wrongly diagnosed him with tonsillitis and gave him antibiotics, the inquest heard.
Over the next 24 hours his condition deteriorated and his parents called 999 when he became unconscious. He went into cardiac arrested in the back of the ambulance and a back-up crew was called.
He was delayed in getting to hospital after the back-up crew went to the wrong location. Toby was later taken into theatre at Dorset County Hospital in Dorchester but died at hospital that night.
Toby's father, Peter Hudson, described the day of his son's death on July 4, 2019 as he returned home to find him under a blanket and looking pale.
He helped him into the wet room of the house where his son's eye's rolled back in his head, there were bubbles of spit in his mouth and he briefly lost consciousness.
Mr Hudson said: "I felt there was no urgency. I had to press for action to be taken and for our concerns to be heard.
"There were issues with communication. The back-up crew went to our home address and at from what neighbours have told me they had trouble finding the house.
"They were knocking on doors before they realised what had happened.
"They then had to travel almost three miles to where the ambulance actually was through Weymouth summer traffic and through roadworks.
"We have a lot of concerns about his care."
Dr Brook said the correct procedures had been followed. According to national guidelines, temporary residents should only be seen by a GP if they do not require urgent care.
Nurse practitioner Briony Jefferis said she was 'not remotely worried' about Toby's symptoms when she examined him at the urgent care centre in Weymouth Community Hospital, saying he 'did not show any signs of sepsis '.
The inquest continues.