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A popular football coach died of Covid-19 after ambulance staff had problems finding him as he struggled for breath.
Now, a coroner has warned that unless greater efforts are made to track down people making emergency calls, future deaths could occur.
Mid-Kent and Medway coroner Sonia Hayes raised concerns following an inquest into the death of father-of-four Steve Cooke, 35, from Gillingham.
Mr Cooke, who was found dead by police on Boxing Day, was assistant manager of the U13s’ side at Anchorians Football Club and worked as a maintenance man at Warren Wood Primary School.
In the aftermath of his death, tributes were paid to the much-loved football coach and family man, and a fundraiser was set up to support his loved ones.
The inquest, which concluded on July 23, heard he had tested positive for coronavirus on December 23, and on Christmas Day, rang 999 suffering with extreme shortness of breath.
The call handler struggled to understand him and after a clinical assessment an ambulance was sent within 26 minutes.
It arrived within five minutes, but was at the wrong address and Mr Cooke could not be found.
The crew checked the address with the operations control and gained access from another key holder, but after a thorough search and enquiries with neighbours, found the property unoccupied.
The control room then tried calling a telephone number on their system to attempt to obtain Mr Cooke's correct address, but the number belonged to his ex-partner, who he was not with.
Ms Hayes has now issued a Prevention of Future Deaths Report to the Chief Executive of the South East Coast Ambulance Service NHS Foundation Trust, raising several concerns.
She said the call handler terminated the call to Mr Cooke’s ex-partner within 62 seconds - a very short time considering the serious nature of the query to find a missing sick patient - and did not give a full explanation for the reason for the call.
Ms Hayes said the call handler did not ask for Mr Cooke's current address - instead suggesting part of the address the crew had been sent to knowing he could not be found there, and did not listen or give enough time for her to respond.
"In my opinion action should be taken to prevent future deaths"
She said the call handler also failed to update Mr Cooke's ex-partner when he could not be found.
Ms Hayes continued: “Mr Cooke was very unwell and in need of medical attention.
"The matter was not escalated further when Mr Cooke could still not be located.
"The original call was not listened to again to attempt to establish the correct address being given by Mr Cooke.
"It was possible to hear Mr Cooke stating with difficulty the word ’opposite’ when part of the address was given."
Mr Cooke was found dead at his home the following day by police carrying out a welfare check after concerns were raised by his family.
In her letter, the coroner - who recorded a conclusion of natural causes - said: “In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action.”
The Trust has until October 5 to respond, giving details of what steps have been or will be taken, or explaining why it is felt that no action is necessary.
A spokesman for the South East Coast Ambulance Service NHS Foundation Trust (SECAmb) said: "Our thoughts and condolences are with the family of Mr Cooke and all those who knew him.
“We take any concerns raised by a coroner seriously and prior to receiving this report we were already undertaking a review of any responses to wrong addresses to ensure we do everything we can to mitigate against a similar event occurring.
“We will respond directly to the coroner as required to take forward any further learning.”
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