A coroner in Donegal has asked for a review of the availability of patient records to out of hours medical services.
Dr John Cannon made the call at Buncrana Coroner's Court at the inquest into the death of a 21 year ol;d man from Glengad who died in February 2009 after visiting the NoWDOC service.
The inquest heard that Martin Mc Laughlin, who suffered a rare medical condition, was taken ill with chest pains and went to the NoWDOC centre.
His aunt who drove him to the centre had told the secretary that in the past he had suffered from a collapsed lung and sore skin which wouldn't heal when cut.
After an hour's wait, he was seen by a doctor, given painkillers and sent home. The doctor said he should contact his GP or go to A&E if symptoms persisted. However, shortly after leaving the centre, Mr Mc Laughlin collapsed.
The doctor was called to Glengad cottages where he administered CPR for almost 20 minutes before Martin Mc Laughlin was pronounced dead.
Dr Cannon returned a verdict of "medical misadventure", and called for a full reivew of how the NoWDOC service access computer records.
He also said the triage system whereby patients are initially assessed by non-medical personnel needs to be reviewed.