Percival Bend (87) died three weeks after suffering serious neck injuries when the wheelchair he was sitting in tipped up in the back of a Derbyshire Community Health Services ambulance.

Mr Bend, of Longedge Lane, Wingerworth, was being driven home after a physiotherapy appointment at Clay Cross Hospital when the incident happened on July 9 last year.

Experienced ambulance driver Susan Ward told an inquest into Mr Bend's death at Chesterfield Magistrates' Court that she had been driving the Renault Master vehicle and her colleague David Cantrill had secured Mr Bend's wheelchair using ratchet clamps.

She said that they had dropped another patient off on Nottingham Drive and she was just pulling away when they heard a bang as Mr Bend's wheelchair fell backwards.

Ms Ward said that Mr Bend seemed "really with it" initially but took a turn for the worse when they arrived at his home and he was rushed to hospital by ambulance.

Following an operation on his spine, Mr Bend died at Sheffield's Northern General Hospital on July 27, 2008 after suffering from bronchopneumonia.

Consultant pathologist Dr Christopher Stonard said the development of the bronchopneumonia was directly contributed to by the acute cervical spinal cord injury he had sustained as a result of the fall.

Mr Bend's son, Kevin, told the inquest that his dad, a retired bus driver, had suffered a stroke in January 2008 but had been making a good recovery and was attending physio appointments twice a week.

"He was trying his hardest to get back on his feet because he didn't like being in his wheelchair," he said.

Expert witness Maurice Rand, from the Government's Medicines and Healthcare products Regulatory Agency, said that there was nothing wrong with the wheelchair or the clamps used, and if fitted correctly they should have worked.

David Cantrill, who was new to the job and had not received specific training on how to secure the type of wheelchair Mr Bend was using, said he was sure the brakes were on and clamped it as he had been taught.

But he conceded to police that marks made on the frame of the wheelchair during the incident suggested it had not been clamped in the best position.

Melanie Buxton, from the Patient Transport Services department at Derbyshire Community Health Services, told the inquest that a number of changes had since been made to improve safety. She said ratchet clamps were no longer used when carrying wheelchair users and had been replaced with more effective restraints.

Recording a narrative verdict, Deputy North Derbyshire Coroner Nigel Anderson, said that Mr Bend had died as the result of an accident "in an NHS vehicle when the wheelchair that he was in, and which was insufficiently secured, tipped backwards, causing him to suffer injuries which ultimately led to his death."

In a statement Tracy Allen, managing director of Derbyshire Community Health Services, said: "We want to express our deepest sympathy to Percy's family at this difficult time."

She said "extensive" action had been carried out which included upgrading vehicles with protective equipment and introducing an enhanced training programme for staff.

In a statement, Mr Bend's family said they were grateful to have secured answers to some of the questions they had following his tragic death.