A South Australian man who died from a heart attack may have survived if proper action had been taken in relation to a blood test, a coroner has found.
Wayne Mitchell, 49, suffered chest pain at work in November 2015 and was taken to a medical centre at Murray Bridge, east of Adelaide.
A troponin blood test to check for signs of a heart attack was taken but not properly followed up despite indicating possible heart damage, coroner Mark Johns found on Thursday.
Mr Mitchell was allowed to leave after his symptoms disappeared but was found dead in his home three days later.
He was thought to have died soon after the initial incident.
Mr Johns said the treating doctor at the Bridge Clinic, Jose Valerio, had failed to follow the chest pain protocol and should have acted on the blood test result as soon as he was told about it.
"I have no hesitation in accepting evidence that had he done so there is a strong possibility that Mr Mitchell may have survived," the coroner said.
Mr Johns said during his evidence Dr Valerio had apologised to Mr Mitchell and his family and recognised his management of the patient was not up to the standard he expected of himself.
Dr Valerio had told the inquest that "undoubtedly a better management would have most likely resulted in Mr Mitchell's survival", Mr Johns said.
Following Mr Mitchell's death, the GP was referred to the Australian Health Practitioner Regulation Agency and was required to undergo remedial education in relation to patients presenting with chest pain.
In December 2017, AHPRA advised Dr Valerio it had removed a requirement for him to work under supervision.
Mr Johns said it was submitted by the doctor's counsel that he was now a better and more skilled practitioner than at the time of Mr Mitchell's death.
"Whether that is so is a matter that can only be judged in the light of future events," the coroner said.