The 51-year-old man – who the Evening News has agreed to name only as Shaun on his family’s request – visited Slateford Medical Centre complaining about pains in his chest and left arm.
Shaun, a smoker with a family history of cardiovascular disease, was seen by a nurse practitioner, but left with just stomach acid medication.
The grandad was found collapsed in the bath two days later on July 31, 2013, having suffered a massive heart attack.
His care has now been criticised by the Scottish Public Services Ombudsman (SPSO), which ruled Shaun was showing “symptoms which warranted further assessment”.
In a report, it said that no chest examination was carried out and that had he been referred for an electrocardiogram (ECG), which records the electrical activity of the heart, his death might have been prevented, although there is no way of knowing for certain.
Shaun’s sister said the family was still waiting for an apology from the surgery.
She said: “When I sit watching something similar happen on television, I think even I know what’s coming. Why didn’t they?
“People said he was grey, sweating profusely and complaining of pain in his chest and left arm, but being the stubborn so-and-so he was, he said ‘I’ll be fine, stop making a fuss’. One of the first things the practice said to me when I wrote to them was that they didn’t see him often, but that should have made them think it must be serious.
“If he had been sent to hospital but if they had done the ECG and other tests, he might have been given treatment to stop what happened.”
Following his death, the practice conducted its own investigation and cleared the staff member of wrongdoing.
But the SPSO has now ordered it to say sorry and review the level of education and training required to carry out the nurse practitioner’s role
Ombudsman Jim Martin said: “He had demonstrated a number of signs and symptoms which should have alerted the nurse practitioner to further examination and referral. As a result, he did not receive further investigation or treatment, which may have resulted in a different outcome.”
Shaun’s sister said she hoped the Slateford practice would learn lessons from the case.
But she added: “I can’t imagine any apology they write is going to be worth reading.”
NHS Lothian did not respond to a request for comment.