The man first called SOS Alarm, Sweden’s emergency response service, in the early hours of January 30th, telling operators he was having trouble breathing, the Dagens Nyheter (DN) newspaper reports.

The nurse who took the call nevertheless judged the man’s condition to not be life threatening.

A short time later, the 23-year-old called again, explaining that he had fainted as soon as he had tried stand up, but again, no ambulance was sent.

“They talked for a total of 12 minutes. Our son repeated time and again that he needed an ambulance and wondered if one was on its way. He even opened the door so that it would get inside. But help never arrived,” the 23-year-old’s stepfather told DN.

The on-duty nurse instead referred the case to an on-call doctor, who called the 23-year-old several times, but never received an answer.

However, no other emergency personnel were sent to the man’s residence to check on his condition.

Several hours later the 23-year-old was found dead by a neighbour. The cause of death was a ruptured spleen.

The man’s stepfather told the newspaper that his son had been suffering from periodic fevers and abdominal pain for months prior to the incident. Despite several health clinic visits, no relevant tests were taken to get to the bottom of the 23-year-old’s ailment.

SOS Alarm has now referred the case to the National Board of Health and Welfare (Socialstyrelsen) according to Sweden’s Lex Maria, the informal name used to refer to regulations governing the reporting of injuries or incidents in the Swedish health care system.

The 23-year-old’s parents have also reported those responsible at SOS Alarm.

“Our own investigation of what has happened and the health board’s investigation isn’t over yet, said Lars Engström, head doctor at SOS Alarm, to the TT news agency.

He added, however, that the nurse who took the call no longer works for the emergency call service.