An inquest found that a 'gross' medical failure at a GP surgery contributed to the death of a 53-year-old man, Dr Mark Ryan Foster.
Dr Foster, a university researcher, died at home on February 17, 2024, due to a pulmonary embolism after experiencing shortness of breath from December 2023.
The coroner's report raised concerns about the governance of Dr Foster's GP practice, Castlegate and Derwent Surgery.
A chest x-ray carried out on January 11, 2024, was 'unremarkable', but Dr Foster's continued symptoms prompted him to return to his GP.
Senior coroner for Cumbria Kirsty Gomersal published a Prevention of Future Deaths Report on October 20, 2025, following the inquest.
Author's summary: Gross medical failure contributed to death.