SENT home from Hereford Hospital as constipated, Trevor Smith had only hours left to live.
An inquest in Hereford heard that the severe stomach and back pains that took Mr Smith to A&E were the first signs of an aneurysm - the excessive swelling of an artery - about to burst.
But when the symptoms mimicked so many other less serious conditions, like constipation, the duty doctor could not 'sell' Mr Smith as an overnight stay, let alone an ultra-sound scan in the middle of the night.
In evidence, Dr Stephen Katona said two hours of tests and checks on Mr Smith, 70, from Bodenham, showed no sign or 'clinical suspicion' of what was to come.
"Unfortunately I allowed (Mr Smith) to go home. In retrospect I should have kept him in," said Dr Katona.
County A&E consultant Andrew Ballham backed Dr Katona's call, saying it was a 'fine judgement' with little leeway over available beds where Mr Smith's symptoms fitted so many conditions.
Pressure
"We try not to send people home in the middle of the night. The majority of times we get it right," said Mr Ballham.
The inquest last Thursday was told that the pain Mr Smith felt was probably caused by pressure on nerves as his aorta - the main artery taking blood from the heart to organs and limbs - began to rupture and bleed into surrounding tissue.
Mr Smith, who died at home last March, the day after being sent home from hospital, had a long-standing heart condition.
County coroner David Halpern ruled Mr Smith's death as due to 'natural causes'.
An overnight admission would have been ideal, said Mr Halpern, but the numbers presenting at A&E with similar symptoms made it unrealistic to expect enough beds.
Dr Katona's diagnosis was not, said Mr Halpern, made 'speedily or slightly'.
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