A coroner at the inquest into the death of a Portadown teenager in Craigavon Area Hospital four years ago said opportunities had been lost during his care.
Patrick McGurgan said 19-year-old James McMaster should have been seen by a consultant over the weekend of May 11-14, 2012.
James, a talented rugby player, died a few days later, on May 16.
Mr McGurgan said that if antibiotics - to which it has since emerged James had suffered an adverse reaction - had been withdrawn even by May 11, the outcome would have been different.
And he said he would be writing to the Health Minister to raise greater awareness among the medical profession of DRESS Syndrome (Drug Reaction with Eosinophilia and Systemic Symptoms).
The inquest, held at Craigavon Courthouse over three days this week, heard from Dr Sara Hedderwick, a consultant in infectious diseases at the Royal Victoria Hospital in Belfast.
She testified that DRESS Syndrome is very little-known within the medical profession, and that consultants are often reluctant to withdraw antibiotic treatment.
The court heard that James had exhibited symptoms of DRESS Syndrome, including rashes and fever.
James, a civil engineering undergraduate, died in the hospital’s intensive care unit, where he had been transferred after his condition worsened.
The teenager, who had turned 19 just three days before his death, had gone to the’s hospital Emergency Department on April 9 complaining of a severe pain in his left buttock. He was diagnosed with a muscle tear and sent home but was admitted by ambulance the following day.
Mr Gurgan said he hoped lessons learned from the inquest would prevent further tragedy in the future.
He said James was a much-loved son and brother, a quiet boy who did not complain and who loved sport.
Conleth Downey, solicitor, made the following statement on behalf of the family: “The family of James are sincerely grateful for the findings of the coroner, Mr McGurgan.
“It is eternally reassuring to the family that concerns raised regarding the lack of knowledge of DRESS Syndrome and the serious consequences of this lack of knowledge are now to be referred by the coroner to the Minister of Health.
“Going forward, with lessons learned and real changes implemented in how medical care is administered, in future other families may avoid the heartache as encountered by the family of our beloved son and brother James.”
A spokesperson for the Southern Health and Social Care Trust said: “The Southern Trust completed its own internal investigation into James’s death and we have already implemented many of the recommendations identified by the coroner today. We will be implementing further changes in line with the recommendations made by the coroner in his findings. In particular, the Southern Trust will be ensuring there is raised awareness with medical staff of the potential of DRESS syndrome when treating patients with antibiotics.”
It extended its condolences to the McMaster family on their loss.