A confused grandfather fleeing hospital staff working to heal his broken wrist died after trying to escape through a fire escape on to scaffolding.
Reggae guitarist Peter Watson, 51, broke his wrist in a bicycle crash on December 20, 2013.
However, on December 22, just minutes before he was due to be operated on in St George’s Hospital, in Tooting, fled the theatre room, through a fire escape and fell to his death.
Westminster Coroner’s Court heard on April 17 that after his bike crash Mr Watson, of Cortis Road, Putney, attended four different hospitals, Kingston, Charing Cross, Chelsea and Westminster and St George’s.
Each time he was described as being angry and aggressive; adamant he did not want to be operated on under general anaesthetic.
At St George’s he developed a good rapport with Dr Mo Akhavani who agreed to use a regional block, rather than full anaesthetic.
Assistant theatre practitioner Oliver Lambden, said he noticed Mr Watson displaying signs of mental health problems as they waited to begin surgery.
He said: "He was talking about music and south west London but there was something bubbling under the surface. He was asking me irrational questions sometimes - he was asking me if his arm was dead and why wasn’t he dead."
Mr Watson suddenly began swinging his arms aggressively and ran out of the theatre past Dr Akhavani who ran after him, into another theatre and out into a "dirty corridor".
Mr Watson kicked open a fire door and ran out onto the roof where it was raining and dark.
The court heard Mr Watson, whose arm was paralysed due to the anaesthetic, ducked under a fence and made a leap for the scaffolding adjacent but fell a considerable distance to the ground and suffered serious injuries.
His daughter Nishell was at his bedside for 24 hours after his fall and following his death his organs were donated.
A serious incident investigation found no genuine way in which the incident could have been avoided.
The court heard Mr Watson had experienced a difficult childhood. He also suffered a head injury during a road incident in 1996 when he was hit by a lorry and was registered disabled after the incident.
Coroner Dr Shirley Radcliffe recorded a verdict of accidental death
She said: "What triggered that sudden bizarre reaction in the operating theatre?
"Was it a culmination of everything - he had attended three different hospitals and not much sleep and spent a large part in pain and had drunk very little.
"Tragically a combination of darkness, the rain, possible mental state and paralysed arm meant that he fell. I can therefore record this conclusion as accidental death."
Mr Watson, who grew up in Balham and Tooting, was described by his family at his funeral as an outspoken, knowledgeable and unique individual.
Mr Watson's funeral was led by Methodist Minister Rev Hewie Andrews in Streatham Park Cemetery, on February 21, 2014, and was attended by over 100 family members and friends.
The event featured African drumming and singing by his cousin Noel Mckoy and sister Melody Ewens.
His family thanked the charity Action against Medical Accidents who represented them during the inquest.