A coroner is writing to the Health Secretary after a former Concorde pilot died from deep vein thrombosis following a delay in his hospital treatment.
British Airways pilot Captain James Bedforth, 51, should have been treated 'within an hour' on arrival at hospital after collapsing at home, according to an expert.
Instead he was only medically assessed two-and-a-half hours after admission at Barnsley District Hospital and had to wait for blood-thinning drugs which could have saved his life.
The Sheffield inquest heard the normally fit and healthy BA pilot had experienced a shortness of breath at Shanghai, China, the day before he flew back and collapsed.
The hearing was also told that the pilot, who was married to Catherine Bedforth, 54, had visited the hospital two months previously with a pain in his leg.
But Coroner Chris Dorries said he was not given a full leg scan which 'might have provided valuable treatment'.
Despite medical investigations in accordance with NICE guidelines, blood clots in his lower left leg were not detected and he was discharged only to be re-admitted on June 29, 2015 - only to die a day later.
Sheffield coroner Mr Dorries is writing to the Health Secretary about the case and inviting him to consider 'whether further, up to date, research might now be appropriate into the potential benefit of lower leg scanning.'
He also criticised the hospital for not giving Captain Bedforth 'safety net' information after his first admission outlining that symptoms such as shortness of breath should result in immediate medical attention 'or his life could be in danger.'
Doctors were aware his record of flying could raise the odds of him contracting DVT but two experts told the inquest that the delays in his treatment were 'significant'.
Anaesthetist Dr Ye Myint, who has written guidelines on treating DVT patients, said the pilot should have been seen within an hour.
He told the inquest: 'My personal opinion is that the delay may have changed the outcome.'
Dr Julian Humphrey, an emergency medicine consultant at the hospital, said there were 'significant delays' in Captain Bedforth being seen by a doctor.
Mr Dorries said the hospital did have an information sheet to give to patients but he was 'less than convinced' from the evidence he heard that the pilot had been given one.
Captain Bedforth did not mention the shortness of breath he suffered in China to anyone including his wife Catherine, 54, until he collapsed at home in the village of Wortley, near Barnsley.
The coroner said: 'Clearly Captain Bedforth was a very intelligent man who found himself in China in the midst of a long-haul flight.
'I'm sure he was the type of person that had he been told about the shortness of breath issue, he would have acted upon this immediately.
'Wherever he was, whatever the local services were, his company had arrangements in place that would have given him decent quality medical advice when he needed it.'
However Dr Rhona Maclean, an expert in thrombosis, told the inquest she did not believe Captain Bedforth would have survived even if he had been seen immediately and treatment started.
Pathologist Yota Kitsanta said a blood vessel in the pilot's brain had become swollen because of a blockage caused by debris from a blood clot.
It was unclear whether this was from the DVT in his left calf or from a secondary thrombosis caused by that condition.
In reaching his conclusions, the coroner said: 'I am reinforced in my suspicions about a lack of detailed 'safety-netting' because I consider it unlikely that a senior pilot of Captain Bedforth's experience would have placed himself on duty on the flight deck of an aircraft if he had considered himself likely to collapse or thought himself potentially seriously ill.'
He said he formed the view that the pilot 'had not realised the seriousness of his breathlessness.'
The pilot was given a blood-thinning drug at more than three hours after admission on the second occasion which Dr Fletcher said should have been given two hours post-admission 'at the very latest'.
But Mr Dorries said he could not say the pilot would have survived if treated earlier.
The pilot was given too much blood-thinning medication which led to over anticoagulation and this led to a fatal brain haemorrhage.
Mr Dorries recorded the cause of death as cerebral haemorrhage due to a significant pulmonary embolus and paradoxical embolus to the brain (treated) due to deep vein thrombosis.
He considered whether negligence played a part but decided that none of the issues raised would have prevented the pilot's death.
He recorded a narrative conclusion and added: 'Captain James Michael Bedforth died at the Barnsley Hospital on 30 June, 2015 in consequence of the treatment given to him, seemingly in accordance with the hospital protocol, for a pulmonary embolus including a paradoxical embolus to the brain.
'While there were some delays in the provision of treatment these cannot be shown (to the necessary standard) to relate to the cause of death.'
The pilot's widow Cathy said afterwards of the coroner's intention to write to the Health Secretary: 'I hope it will make a difference to somebody else.'