An air ambulance doctor killed himself after mistakenly administering a drug to a patient that led to his death.
Dr Carl McQueen, 34, was devastated after being told an investigation was to be launched into the death of Lee Hanstock.
Dr McQueen administered a sedative to Mr Hanstock, 43, after he suffered a seizure, but the drug caused his blood pressure to drop rapidly and he went into cardiac arrest.
The air ambulance doctor took his own life at his grandfather's house in Solihull, West Midlands, after learning his drug blunder contributed to the death of the father-of-four.
An inquest into Mr Hanstock's death, in Burton-upon-Trent, Staffordshire, heard that he had never before been known to have ill-health and had not seen a GP for 15 years.
Mr Hanstock, from Barton-under-Needwood, also in Staffordshire, started feeling unwell just after Christmas 2015, suffering from severe migraines and nausea, and vomiting 15 times in a day.
After calling 111, he travelled with his wife, Amy Tipper, to the Cross Street Surgery in Burton-upon-Trent, on December 28, where he waited for two hours before being seen.
The doctor realised he was suffering from acute hypertension, a rare condition which involves blood pressure becoming so high that it can cause permanent organ and brain damage.
Immediately he was sent to the Accident and Emergency Department at Queen's Hospital in Burton.
When he arrived, he had 'remarkably high' blood pressure and was given a series of treatments to attempt to bring it under control.
However, Mr Hanstock was not given an ECG, which could have saved his life, the inquest heard.
Dr McQueen administered a sedative to Mr Hanstock (pictured) , 43, after he suffered a seizure, but the drug caused his blood pressure to drop rapidly and he went into cardiac arrest
He was then sent home despite his wife questioning the results of a CT scan, which she was told 'looked fine'.
Staff were aware that Mr Hanstock was suffering from hypertension, but he was discharged without medication to deal with the problem and simply told to contact his GP about a migraine.
Six hours after being admitted to hospital he was back at home. Less than 24 hours later he was dead.
Dr Tarunya Vedulta, one of the team of people responsible for discharging Mr Hanstock, was in tears as she told the inquest she thought that the symptoms could have been dealt with at home.
She said: 'We saw that he had long-standing hypertension, which I thought were being exacerbated by his migraine and a chest infection. He was responding to treatment, and I thought those symptoms would continue to get better when he left hospital.'
Asked if she saw ECG results, she said: 'I thought I saw an ECG. I honestly did. All the paperwork tends to be loose so it could have been someone else's. It's all loose.'
Twenty-four hours later, Mr Hanstock suffered a seizure at his home and his family dialled 999.
When ambulance crews arrived, Dr McQueen gave him an injection of 500mg thiopentone to sedate him so he could be safely moved downstairs to take him to hospital. A suitable dose would have been '250 or 300mg'.
The drug caused his blood pressure to drop rapidly, which was not picked up on quickly enough by the crew, and he went into cardiac arrest.
Dr McQueen committed suicide on February 12 last year after learning that the ambulance service were investigating the incident.
The inquest heard how Dr McQueen's wife, Kirsty, a former nurse, and their two children lived in Nottinghamshire, while he stayed at his grandfather's house.
He was juggling shifts at the Midlands Air Ambulance at Cosford with doing his Phd at Warwick University and also doing locum work as an emergency doctor in Derby.
Magnus Harrison, the Burton Hospital NHS Trust's executive medical director, led the serious case review into what happened to Mr Hanstock. He said rigid procedures had been put in place to ensure that lessons were learned.
Summarising, Mr Henstock's family's lawyer, Dr Peter Ellis, said: 'This is an unusual case in the sense that there were multiple opportunities to do things in Lee's case.
'There was a failure to perform an ECG, a failure to see the significance of the CT scan, the missed opportunity to seek senior review about the premature discharge when his blood pressure was still very high and he remained confused.
'In addition to that, there's the excessive dose of thiopentone and a failure to recognise the hypertension that resulted from that.'
Giving a narrative conclusion South Staffordshire Coroner Andrew Haigh said 'This is a natural death but there have been a number of significant failings.'
He recorded a cause of death as 'natural causes, where the death could have been avoided through suitable treatment.'
But he said he was satisfied the hospital had learned from the robust action plan which now exists.
After the hearing Mr Hanstock's wife Amy Tipper said: 'Lee was a wonderful caring father, son and partner, with a big personality who filled our lives with love, laughter and fun.
'It is devastating to know that his death was avoidable, and that had appropriate treatment been provided our family would still be complete.'
Joe Tipper, Amy's brother, said: 'It has been difficult for Amy, Lee's parents and family to come to terms with what happened, especially given the time of year.
'The actions of Dr McQueen, for whose family we have nothing but the greatest sympathy for their equally tragic loss, were well-documented.
'However, what makes our loss even harder to bear is the knowledge that it could have been prevented at a much earlier stage.'
A West Midlands Ambulance Service spokesman said: 'The Trust apologised to the family of Mr Hanstock following his death in 2015.
'The coroner concluded that Mr Hanstocks death was due to 'natural causes' but noted that there were several failures in his care by the NHS which contributed to his death.
'A serious untoward incident was raised by West Midlands Ambulance Service at the time and an extensive internal investigation was carried out. The Trust has since taken appropriate steps to ensure a similar incident is not repeated.
'Our thoughts remain with the family of Mr Hanstock and we offer our sincere condolences to them.'
Burton's Queen's Hospital declined to comment.