A doctor fluffed a resuscitation procedure on a dying Battersea man at St George's Hospital, an inquest heard on Friday.

Robert Croucher, 39, of Grayshott Road, died of brain damage after doctors misdiagnosed his condition and later performed CPR incorrectly, Westminster Coroner's Court was told.

The incident sparked a Serious Untoward Incident (SUI) investigation, which led to more staff training at the hospital.

Dr Mike Bailey, who led the investigation, said: “Certainly things weren't done as well as they could have been, which could therefore increase the risk of hypoxic brain damage.”

The court was told Mr Croucher, a well-travelled former gardener who led a normal life but was addicted to heroin, arrived at the hospital on March 25 this year.

His GP had referred him urgently after complaints of blurred vision and slurred speech, and staff carried out tests for stroke.

But a post mortem later showed the patient was probably suffering from a botulism – an infection possibly caused by using dirty needles or a contaminated batch of heroin which was circulating in London at the time.

On April 3, Mr Croucher resisted lying down for a scan and was moved to the waiting room, where he was left alone and had a heart attack.

When staff realised something was wrong, the right equipment was not to hand and one doctor did not perform CPR chest compressions with enough pressure – according to a nurse witness.

When the resuscitation team arrived less than four minutes later, they tried their best but Mr Croucher could not be saved.

Dr Shirley Radcliffe, the coroner, said: “We are not in a position to say whether these errors made any significant contribution to Mr Croucher's death because we are not entirely sure what it was."

She added: “Whatever the cause, there isn't any evidence of an unnatural cause of death.”

She said Mr Croucher died of hypoxic ischaemic encephalopathy due to a suspected botulism, and recorded a verdict of death by natural causes.