The care of a severely anorexic woman prompted 14 recommendations for change, an inquest has heard.
Madeline Wallace, from Peterborough, died in January 2018 from sepsis.
An independent review highlighted a lack of knowledge about complications, such as infection, by GPs and hospital A&E staff.
The inquest heard Ms Wallace, 18, visited A&E and her GP surgery in the days before her death but an infection went undiagnosed.
Ms Wallace was more susceptible and less able to fight infection due to her anorexia, the coroner was told.
The independent review of her care was commissioned by Cambridge and Peterborough Clinical Commissioning Group following concerns raised by her family.
It made 14 recommendations for changes to prevent gaps in care at a national and regional level, the inquest heard.
They included advice for A&E staff and GPs on anorexia complications and a need for quicker blood test results taken during regular GP check-ups to be shared more quickly with eating disorder specialists to prevent “worrying” signs not being picked up.
Maria Dineen, who wrote the report, said: “It would help in recognising signs, it will make a significant difference for vulnerable people in the future.”
The inquest previously heard Ms Wallace had been rejected for an urgent hospital admission in the days before her death and sent home with antibiotics.
Dr Jaco Serfontein told the inquest it would likely be “difficult” for general doctors to pick on on potential signs of infection in regular anorexia blood tests, unless the person also showed symptoms.
Ms Wallace’s family said she had told a GP and A&E staff about chest pain but infection was not diagnosed until an emergency hospital admission.
Following the review North West Anglia Foundation Trust, which runs Peterborough City Hospital where Ms Wallace died, said it had made changes recommended in the report, including automatically notifying GPs of any hospital admissions.
Cambridgeshire and Peterborough Foundation Trust said changes were being made to how it monitored high risk patients.
The inquest continues.
If you are affected by any of the issues in this story, you can talk in confidence to eating disorders charity Beat by calling its adult helpline on 0808 801 0677 or youth helpline on 0808 801 0711.