A former parish council chairman died after errors were made in his hospital treatment following a fall.

David John Hobbs fell at his home while installing Christmas lights above a doorway on December 22, 2022, Swindon and Wiltshire Coroners’ Court heard on Thursday.

But when ambulance staff transferring him noticed he had slurred speech, they were concerned because he had suffered had a stroke nine months earlier.

Doctors administered thrombolysis, known as “clot buster” medicine, which caused Mr Hobbs’ blood pressure to rise.

It was later revealed the retired printer, who was previously chairman of Ramsbury Parish Council, was suffering from an intracerebral haemorrhage, which the medication had made worse.

The 88-year-old died at Princess Lodge Care Centre on Curie Avenue, Swindon, on January 13, 2023.

Dr Tim Slade, of Great Western Hospital, said that “lessons had been learned as a result” of Mr Hobbs’ death and that a memo had been distributed among staff to change the hospital’s policy to double-check for such issues before the administration of thrombolysis.

The inquest heard that a CT scan and radiology report were performed before the administration of the treatment, and, seeing no indication of an intracranial haemorrhage which would contraindicate such medication, Dr Abdulrahman Alsawadi issued instructions for it to be administered.

Dr Alsawadi said there was no cause for concern until Mr Hobbs’ blood pressure rose in reaction to the treatment.

Despite thrombolysis being stopped, Mr Hobbs’ condition continued to worsen, with medical practitioners unable to successfully administer nutrition.

The family were adamant that Dr Alsawadi maintained very open lines of communication and displayed professionalism throughout the ordeal.

Richard Bardsley, 59, the partner of Mr Hobbs’ youngest daughter, Jules, 60, said: “Alsawadi was a very kind, professional man.”

Jules, Richard and Mr Hobbs’ oldest daughter, Jina, 64, took turns reading a final statement on behalf of the family.

They said: “We want the outcome of this inquest to be positive, to go forward with recommendations to improve the service.

“We’ve read Great Western Hospital’s Patient and Safety Incident and Investigation report and don’t want the mistakes made through the treatment procedure that Dad received to be repeated.

“We have no doubt the aim of the doctor leading Dad’s treatment was to his very best but it seems procedural errors prevented the required standards from being reached.”

Mr Hobbs’ family said they hoped to see the policy changes adopted across the whole of the NHS.

The causes of Mr Hobbs’ death were listed as aspirational pneumonia, poor swallowing, “traumatic intracerebral haemorrhage [exacerbated by thrombolysis]” and previous stroke and chronic obstructive pulmonary disease.

The coroner ruled his death was misadventure.

UPDATE: After publication, the Salisbury Journal received a response for previous requests for comment from Great Western Hospital regarding the incident.

A spokesperson from Great Western Hospitals NHS Foundation Trust said: “We’d like to offer our deepest sympathies to Mr Hobbs’ family following his sad death. We are sorry that the care we provided fell below the standard we would expect, and we have been in regular contact with the family to keep them updated on the investigation process and outcomes.

“Following Mr Hobbs’ death, the Trust has made significant changes to patient assessments, which now involve a stroke consultant earlier on in the care of patients with a suspected stroke.  

“Learning has been shared widely with staff across the organisation.”