Doctors missed opportunities to potentially prolong an injured pensioner's life, a coroner said yesterday.
Michael Healey, 77, of South Croydon, was discharged from hospital after radiologists failed to spot a small bleed on his brain caused by a bang to his head.
He died two days later after his condition drastically deteriorated, an inquest at South London Coroner's Court heard on Thursday morning.
Mr Healey, a retired civil engineer, was taken to Croydon University Hospital on March 11 after falling in his Castlemaine Avenue home and hitting his head.
The father-of-two, described as "a wonderful man" by his family, was discharged that day after doctors analysing a brain scan failed to pick up any damage.
But he returned to the hospital's accident and emergency department the next day complaining of headaches.
He went three hours without seeing a doctor and nurses failed to carry out the minimum hourly checks on his condition.
Shortly after being assessed by a doctor Mr Healey's condition went rapidly downhill.
A second brain scan found a large pool of blood on the brain which neurologists said was too serious to be surgically removed.
He died the next day.
Coroner Roy Palmer said Mr Healey, a keen photographer, should have been admitted overnight on March 11.
But he was satifsied that the hospital had since changed procedures to ensure that patients taking Warfarin - a drug prescribed to Mr Healey that makes bleeding more likely - were not discharged soon after suffering head injuries.
Dr Palmer said: "Had he fallen now then he would have been admitted overnight and better observation would have been done.
"Clearly there was a lost opportunity to do something. Hopefully it is of some comfort to the family that action is being taken to improve things."
But he added there was insufficient evidence to conclude that earlier intervention would have saved Mr Healey's life.
He recorded a verdict of accident death, saying: "The reason he died was because he fell and banged his head."
Speaking after the inquest, Mr Healey's daughter Louise Gray said the family was unhappy with the length of his wait for treatment.
She said: "We are really disappointed with how long it took. Had we known what we know now we would have shouted and screamed to get him some attention.
She added: "He was a wonderful man. He had time for anybody. You should have seen how many people were at this funeral. I just wish he hadn't been taken from us so young."
Roger Sears, Mr Healey's son-in-law, said: "He wasn't seen by a doctor for over three hours and it was only the family repeatedly highlighting Michael's deteriorating condition finally got him some attention."
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