An inquest has been told that an 88-year-old woman died a few hours after an emergency doctor called at her bungalow - but left because he could not gain access.
And a coroner said that a lack of medical attention contributed to Sarah Bonner's death at her home in Jarrow, South Tyneside.
Dr Brij Joshi worked for Northern Doctors Urgent Care (NDUC), which is an out-of-hours GP service.
He was called to Mrs Bonner's home in the early hours of a morning where he waited outside for 20 minutes.
Although he heard her shouting to him, he could not get access, and he eventually left after dropping a note through her letterbox, asking her to call back if she needed help.
Her personal carer visited her five hours later, and discovered that she was dead.
Coroner Terence Carney ruled at an inquest that she died from natural causes, and neglect contributed to her death.
The two-day inquest was told that doctors who are unable to gain access to a home after an emergency call-out should contact the police or the council-operated Warden Call Service. However, the 59-year-old doctor, who was employed to cover three night shifts a week for the firm, did neither.
His employers, who provide medical cover for 934,000 people across the North East, will now consider whether to take further action.