A former tailor who made suits for the famous including Frank Sinatra and Norman Wisdom died after doctors failed to spot a blood clot on his brain, an inquest heard.
Great-grandfather John Prina, 84, who was raised in an orphanage, worked on Savile Row in the 1950s and 60s.
He fell over in his garden on August 4 and was rushed to hospital but medics diagnosed a urine infection and sent him home with painkillers and antibiotics.
Smart-dressing Frank Sinatra had suits made for him by John Prina
Hours later he suffered a severe stroke and returned to hospital where a CT scan found there had been irreversible bleeding on the brain.
He died two days after the fall and an inquest heard staff at Darent Valley Hospital, Dartford, had failed to perform an initial CT scan which may have saved the frail pensioner's life.
Coroner Roger Hatch recorded an open verdict and the hospital has announced a review of its treatment of head injuries.
Clinical director of emergency care Dr Winston Martin told the inquest he had reviewed Mr Prina's medical notes and found no signs or symptoms of a head injury.
Kent comic Norman Wisdom was a customer of Mr Prina
He said it was unclear whether the bleeding had occurred before or after the fall but added the incident could also have been caused by his urine infection.
The cause of death was recorded as a subdural haemorrhage after cerebral infarction - another term for a stroke.
Outside the inquest in Gravesend two of Mr Prina's four children Mark, 57, and Douglas, 55, said they did not blame anybody for his death.
Mark said: "I know it was too late then [by Aug 6], but was it too late on August 4? We won’t ever know that.
"Dad said to me [when he left hospital] he had a headache and although it was minor he was in a weak state.
"If he had been admitted then it would have been so much better for him in his last hours of life.
"I do feel it could have been a lot more comfortable for my dad when his time had come."
Regarding the change in policy he added: "It's a good outcome and it seems they realise it was a mistake."
Mr Prina was raised in an orphanage and spent the post-war years in a homeless hostel before being adopted by a working-class London family.
Darent Valley Hospital in Dartford
In the 1950s and 60s he was a bespoke tailor making suits for the likes of Frank Sinatra, Norman Wisdom, amateur astronomer Patrick Moore and other celebrities.
He never got the chance to meet those he dressed but Mark said Sinatra did send him a complimentary note.
Mark added: "Each of the shops in Savile Row had workshops where the tailors worked.
"My dad had a cutter who would forward the pattern to him. He would then make the suit and send it back.
"My father's story is amazing but he was a very self-contained man."
Mr Prina moved to Dartford with wife Bessie, 82, after retiring and she said: "He made clothes for some very famous people.
"My father's story is amazing but he was a very self-contained man" - Mark Prina
"He was almost working for himself and taking trade form Savile Row. He enjoyed his job."
The inquest was almost adjourned after the locum, Dr Baisi Olaogun, who treated Mr Prina in A&E, failed to attend and his absence could not be explained.
Recording an open verdict, coroner Roger Hatch said Dr Olaogun's non-attendance meant the evidence had not been "satisfactory".
He said: "It is also to be noted that the system has been changed so that these situations will hopefully not occur in the future.
"When Mr Prina fell on August 4 and went to Darent Valley Hospital, perhaps all the tests that should have been carried out were not, for whatever reason that was."