A retired IT consultant died three weeks after he had been left lying on the ground for 11 hours while waiting for an ambulance.
Michael Onoufriou suffered a fractured femur when he tripped and fell near his home in Falmouth, Cornwall, in December last year.
An inquest heard the 72-year-old was left traumatised after he had to wait in freezing conditions outside his home for 11 hours before an ambulance finally arrived at 6.48am.
His family had made repeated calls to the South Western Ambulance Service from the time of his fall at 7.32pm the previous evening.
He was finally admitted to the main Royal Cornwall Hospital in Truro at 8.29am the next morning but a bed was not found for him until later that afternoon.
The inquest heard from his family who said they feared he could have died from hypothermia as he waited for the ambulance in -5C conditions while wrapped in blankets.
Michael wrote to the Tory Falmouth and Truro MP Cherilyn Mackrory urging her to intervene to rectify the 'inhuman' situation surrounding his ordeal.
At the time ambulance bosses apologised saying 'handover delays at hospitals were delaying response times'.
They were sorry they could not provide Michael with a 'timely response' adding: "Our performance has not returned to pre pandemic levels, partly due to handover delays at emergency departments."
READ MORE: Ambulance service apologises to Falmouth man left lying on ground for 11 hours
The Truro inquest heard Michael, whose parents were Greek, had worked for IBM as an IT consultant for 40 years before retiring.
His family said he was a very healthy man who led a green lifestyle and was an avid walker and played golf.
Two days after his fall he had surgery on his broken femur and made a very good recovery, and was allowed home.
But they said the long lie waiting for the ambulance caused him trauma and he suffered two panic attacks - which may have been a symptom of the blood clot that had formed, and was to lead to his death three weeks later in January.
The inquest heard South Western Ambulance Trust (SWAST) apologised for their response, blaming high demand and ambulances being taken off the road due to long patient handover delays at hospitals.
On that day alone, the day of his fall, 843 hours of ambulance time was lost and 1,028 hours on the following day when Michael was eventually taken to hospital.
The assistant coroner Stephen Covell said a Prevention of Future Deaths report about these concerns has already been made to the SWAST and the Dept of Health saying: "This is an issue and matters are in hand."
Consultant Dr Anna Longdon said Michael suffered a 'catastrophic' pulmonary embolism having made 'fantastic progress' after surgery.
She said Michael was given blood thinning injections but while they can reduce the risk of clotting, they cannot remove the risk.
A post mortem concluded he died from the pulmonary embolism.
Coroner Mr Covell said the ambulance delay was caused by pressures of demand on the service and being unable to off load patients at hospital causing ambulances to be blocked.
He said insufficient information was given to the patient and his family about the blood thinning injections that his son administered to him, and Dr Longdon apologised to the family for that.
Michael collapsed at home on the evening of January 8, 2023 and his son gave him CPR before ambulance crews arrived in quick time - but he could not be saved.
Mr Covell recorded an accidental death conclusion, saying the unwitnessed fall started the chain of events.
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