A coroner has issued a warning after a dying man was sent a taxi to take him to hospital hours after calling for an ambulance.
Guy Davies said Andrew Waters was 'denied' the opportunity of 'lifesaving treatment' and died as a result of 'systemic failures'.
His comments came after an inquest was told the 56-year-old waited hours for an ambulancebefore the service ordered a cab to take him to hospital.
The taxi driver who took Mr Waters to the emergency department in Cornwall had not been told his passenger was having a heart attack, it is understood.
Mr Waters went into cardiac arrest 'immediately' after arriving at the hospital and his condition became 'unsurvivable'.
In light of his passing, Mr Davies - Assistant Coroner for Cornwall and the Isles of Scilly - has issued a warning to the Department of Health and Social Care highlighting several 'matters of concern'.
The coroner said significant handover delays means ambulances are 'tied up' at hospitals, leading to an 'increased risk in mortality' for patients in the community waiting for emergency services.
Mr Waters' family called 999 at 2.37am on May 24 last year, the inquest heard.
Andrew Waters arrived at Royal Cornwall Hospital (pictured) three hours after the first 999 call was made
The coroner said at this time, he was exhibiting 'clear symptoms of a heart attack'.
The service allocated a category 2 priority - which has a target response time of 18 minutes on average - but there were 'no ambulances available to respond'.
At 4.40am, the ambulance service despatched a taxi which collected Mr Waters and took him to the Royal Cornwall Hospital [RCHT].
He arrived at 5.37am, three hours after the first call was made.
Mr Waters went into cardiac arrest almost immediately after arrival at the RCHT Emergency Department, the inquest heard.
Despite emergency heart surgery, the medical team were unable to save his life.
The coroner said his heart condition was treatable but the impact of the cardiac arrest meant it became 'unsurvivable'.
'The ambulance delay denied Andrew the opportunity of potentially lifesaving treatment,' Mr Davies said.
'Andrew died from an undiagnosed and treatable heart condition, following an ambulance delay attributable to a systemic failure related to the whole system of health and social care.
'The ambulance delay was possibly causative of death in that it denied Andrew potentially lifesaving treatment.'
In light of his passing, Mr Davies has issued a prevention of future deaths report to the Department of Health and Social Care detailing several 'matters of concern'.
Mr Waters went into cardiac arrest almost immediately after arrival at the RCHT Emergency Department, the inquest heard
He said there were 'significant handover delays' on May 23 and 24.
He said at the time of the 999 call, there were seven ambulances delayed at the hospital due to an inability to handover their patients to the hospital emergency department.
The coroner added: 'In Andrew's case the unavailability of ambulance resources meant that the South West Ambulance Service Trust (SWAST) had to resort to sending a taxi to try and get Andrew to hospital in time.
'The taxi driver was not informed that the ride was for a patient having a heart attack.
'Nevertheless, the taxi driver made every effort to get Andrew to hospital as quickly as lawfully possible.'
The coroner said the national target for ambulances to handover patients to hospital is within 15 minutes of arrival.
However, he said on the night Mr Waters was taken to hospital, the average handover time per patient was 50 minutes, 20 seconds per patient.
Mr Davies said: 'Data indicates the picture has not improved.
'Significant average handover delays at RCHT were recorded for every month of 2025 to date.
'This is a picture reflected across the south west and indeed nationally.
'The average handover delays conceal spikes such as that which led to the long delay in this case.
'Such long delays increase the risk of mortality.'
The coroner said the emergency department was 'crowded' on the day Mr Waters attended hospital with patients accommodated on trolleys in corridors, in the waiting room, or inside the ambulance.
He said emergency departments have a target for 95 per cent of patients to be admitted, transferred or discharged within four hours.
Mr Davies said on the day of Mr Waters' death, the hospital 'failed to meet' this target for the 'majority of patients'.
Moreover, he said there was 'insufficient social care provision'.
He said many hospital beds were taken up by patients who are 'medically optimised but cannot be discharged due to lack of onward care support'.
The coroner noted that on the day Mr Waters visited the hospital, 20 per cent of the patients were in this category.
Summarising his 'matters of concern', he said: 'Significant handover delays leading to ambulance resources being tied up at hospital with increased risk in mortality for patients in the community waiting for emergency ambulances.
'[Emergency Department] crowding leading to increased risk in mortality for patients being held in ambulances and corridors and being delayed from receiving surgery or specialist treatment on wards.
'Insufficient social care provision leading to large numbers of patients in hospital who are otherwise fit for discharge, thereby impeding patient flow through hospital.'
The department of health and social care has 56 days to respond to Mr Davies' comments.
