An out-of-hours doctor who "wasted valuable time" by conducting a "bizarre" examination when attending to a dying patient, left medical experts baffled.

An inquest into the death of Philip Osborn, 74, on October 11 2014, heard how Dr Win Hlaing, the on-call doctor who treated him, behaved at a standard "below what is expected from a reasonably competent GP".

He was called to the home, in Kennel Ride, Ascot, by Mr Osborn's wife, Susan, who was caring for him while he was suffering from vocal chord paralysis, a chest infection and suspected urine infection.

Despite Mr Osborn's dislike of doctors she rung the out-of-hours service as she "didn't like the look of him", who ensured her a doctor was on his way.

When Dr Hlaing arrived at the house at 11.39am, he was rushed upstairs to the bedroom where Mr Osborn was lying on the bed, his head propped up by pillows and his legs raised.

Mrs Osborn said: "When the doctor arrived he said he did not like the way he was looking and asked me to call 999, but unfortunately they wanted to speak to him not me."

She said after handing the phone to Dr Hlaing, partly because she was "too emotional" to speak to the operator, she went over to her husband.

She said: "He shuddered and cried out in pain. He wasn't very well so I went to hold his hand.

"His breathing was faltering and he went to put his hand to his face and then the noise stopped."

She said she then asked the doctor if her husband has died and when he said yes, she became "hysterical."

But there was some discrepancy about whether she said had told Dr Hlaing not to resuscitate her husband.

He claimed she had told him not to but she argued that it was only when paramedics arrived that she cried out "don't touch him" as she felt too much time had passed to save him.

However when questioned by Mr Simon Howarth on behalf of the family, Dr Hlaing eventually admitted Mrs Osborn had not told him not to resuscitate her husband and regardless of whether she had done so or not, this would not have influenced his decision-making.

Dr Hlaing, who works as a GP at Burma Hills Surgery in Wokingham, said that when he arrived he told Mrs Osborn to call for an ambulance as he was shocked at Mr Osborn's appearance.

He said that when she was out of the room he examined Mr Osborn for a pulse in his neck, wrist and groin, then checked his chest with a stethoscope and then checked his blood pressure, but Mrs Osborn argued she didn't see any of this happen.

When paramedics arrived, they pronounced Mr Osborn dead.

But questions were asked about whether Dr Hlaing had behaved appropriately as he had not done CPR and whether he wasted time after taking over from Mrs Osborn on the phone to the ambulance service.

He argued that when he came back into the room after finishing with the operator, Mr Osborn's eyes were shut and after lifting his eyelids he could see his pupils were fixed and dilated.

He also argued that the chauffeured taxi he had been driven in, a standard form of transport for an out-of-hours doctor, was not fitted with a defibrillator and that he had not had enough time.

However, Dr Cox from the General Medical Council, said that failing to do CPR when a person has no pulse but is still breathing, is below the expected standard care of a "reasonably competent general practioner". 

He added that fixed dilated pupils showed that Mr Osborn was in the process of dying but had not yet died and that resuscitation attempts would not have been futile, as Mr Osborn was still breathing, indicating it had not been long since his heart had stopped breathing. 

Independent expert GP Dr Neil Lloyd-Jones said: "I am at a loss as to why he tried to ascertain if he had a pulse in three different areas and to check his blood pressure was totally bizarre, a total waste of valuable time.

"I see the clinical rationale of using a stethoscope, but Dr Hlaing failed to appreciate he was dealing with a cardiac arrest in a community setting. 

"Not to be facetious, but I don't know what the man was doing, he might as well have taken his temperature. 

"You have to ask yourself if what you are doing is going to make a difference to the outcome. 

"He failed to realise someone was in cardiac arrest and failed to get to grips with the situation."

He added that Dr Hlaing failed to tell the operator assertively enough that it was an emergency and wasted time in which he could have been given CPR.

However he said the survival rates for cardiac arrests at home for the over 70s is only 20 per cent. 

But he said: "In my mind it is irrelevant if Dr Hlaing had a defibrillator or not. As a GP you just get stuck in; we mustn't lose sight of the fact that was needed here was basic CPR."

However he said it was out of his remit to say whether CPR would have helped save Mr Osborn.

Recording a death of natural causes because of an underlying heart and lung condition, coroner Peter Bedford, agreed no one could be sure whether CPR would have worked. 

He said: "What we know about him is that he was not a well man and the chances of CPR having saved him can not be said definitively one way or another." 

He added that he would submit a report to the East Berkshire Primary Care Out Of Hours Services to make sure all out-of-hours cars are fitted with the relevant equipment, including defibrillators, as the fact that it is currently "hit and miss", is a "surprising shortcoming".