A pensioner who was accidentally given a double dose of anti-clotting medicine died after a massive tumour in his brain started bleeding.

Joseph Penfold, 81, was also subjected to a risky biopsy operation that might not have been necessary and may have caused the tumour to bleed.

His family complained the sick pensioner was left “upset” when staff from his GP surgery told him the devastating news he had a brain tumour over the phone rather than contacting them as they had requested.

But a coroner said she was unable to take any action against doctors and nurses at the William Harvey Hospital despite sharing the family’s concerns.

Dr Ross Lindsay, a GP at Northgate Medical Practice in Canterbury, told the inquest in Folkestone last week Mr Penfold had suffered constant headaches for a number of months and was sent to the William Harvey Hospital for scans towards the end of 2012.

The scans revealed a large tumour at the base of his skull, so big it had started to destroy the bone, and he was given a “fast track” referral for a biopsy.

Doctors initially believed the tumour was malignant but it was only after he died they discovered it was something far less sinister.

Results from King’s College Hospital, only received by doctors after his death on April 5 last year, showed Mr Penfold actually had a prolactinoma – a benign tumour that grows in the brain’s pituitary gland, can often be treated by drugs and is rarely fatal.

Had doctors suspected Mr Penfold, of Rough Common, Canterbury, had been suffering from this less common tumour, a simple blood test would have confirmed it and the octogenarian would not have been forced to endure a risky biopsy operation, the inquest heard.

Mr David Mitchell, a consultant surgeon in the East Kent Hospitals University NHS Foundation Trust’s Ear Nose and Throat (ENT) department, said he had no reason to suspect the tumour was benign since all the signs, particularly the fact it was invading bone, pointed to it being malignant.

After the biopsy Mr Penfold’s oxygen levels were low but as there were no obvious signs the tumour was bleeding and doctors were forced to think of another reason for it, Mr Mitchell continued.

It was decided the OAP probably had a life-threatening clot in the main artery of his lung and he was immediately given a dose of blood-thinning medicine Clexane while doctors waited for scan results.

Dr Philip Brighton, consultant geriatrician at the William Harvey, told the inquest it was “current procedure” to give the medicine before finding out whether the patient was actually suffering from a lung clot, adding that Mr Penfold should have been given one dose every 24 hours.

But less than seven hours after the medicine was given a nurse, who was not called to give evidence at the inquest, gave him a second dose.

Coroner Rachel Redman revealed the nurse claimed to have asked a doctor whether to prescribe the second dose and was told “yes” but the doctor, also not at the inquest, denies this.

“If it could be established that it caused the bleeding I would be taking action but it cannot. I know the family have had concerns about the treatment and I share those but I can’t take further action" - Coroner Rachel Redman

The Penfold family’s representative, Alex Just , said their primary concern was to make sure other patients did not suffer the same fate.

He said: “The family are satisfied the trust has taken steps.”

Mrs Redman recorded a narrative conclusion. She said: “I have genuine and considerable concerns about the erroneous administration of the second dose.

“If it could be established that it caused the bleeding I would be taking action but it cannot. I know the family have had concerns about the treatment and I share those but I can’t take further action.”

Trust spokesman Matt Hogg said: “We would like to express our sincere condolences to the family of Joseph Penfold following his death.

“Although the coroner stated there was no proven link between Mr Penfold’s death and a second dose of Clexane, clearly this should not have happened and we have fully investigated the circumstances around the second dose.

“From this, we have improved our complex prescription procedures and the multi-disciplinary team involved in his care have reviewed their processes around communication of complicated high-risk patients. Patient safety continues to be a priority for us.”