A coroner is to warn of the dangers of bed blocking after hearing how a heart patient who died had to wait more than five-and-a-half hours for an ambulance.
Richard Carpenter collapsed at home two days after surgery and his wife Jeanette called 999 at 10.30pm, an inquest into his death heard.
But the ambulance service was 'swamped' with calls and paramedics were unable to reach him until 4.10am the following morning - even though he was supposed to be seen in 18 minutes.
The inquest heard that at the time of the emergency call, there were 73 people in the area waiting for an ambulance, 42 of which were in the same emergency category as Mr Carpenter.
By the time paramedics got to his Chippenham, home he was unresponsive and had died from bleeding following complications from his operation, the hearing was told.
Senior Coroner for Swindon and Wiltshire David Ridley acknowledged the ambulance delay was "unavoidable" in the "difficult" post-pandemic time in the autumn of 2021 when Mr Carpenter died.
He said he could not guarantee whether or not this "contributed" to the 71-year-old's death.
However, he raised concerns over a 'pressure point' which is affecting the 'NHS world' - bed blocking - and said he would be writing to the authorities to flag the issue.
Salisbury Coroners Court heard the marketing firm managing director was discharged from hospital having undergone open heart surgery on November 28, 2021.
But just two days later, he collapsed leading his wife Jeanette to call the ambulance - at around 10:30pm.
However, he was not seen by an ambulance until 4:10 the following morning, by which point he was unresponsive.
Jon Knight, deputy heard of clinical operations and safety at the South Western Ambulance Service NHS Foundation Trust, described the pressures the health service was under at the time as "incredibly difficult".
Mr Knight told Mrs Carpenter and her relatives: "Can I firstly start off by offering my sincere condolences to the family. I found this case very upsetting."
He added: "It was an incredibly difficult time. I don't think overwhelmed would be too strong of a word to use in terms of demand.
"Really very difficult time for everyone in any care setting due to the Covid pandemic."
Mr Knight said at this time - which was "the peak of the pandemic" - they would 'occasionally' have 750 calls waiting to be allocated to a responder.
The coroner asked Mr Knight whether the "problem of bed blocking" was relevant that night.
Bed blocking is a term used to describe when people are kept unnecessarily in hospital beds for long periods of time, due to delays in arranging outer care.
The coroner said bed blocking is still a 'pressure point' in the healthcare service.
Regarding the delay in an ambulance getting to Mr Carpenter, Bristol-based consultant cardiac surgeon Dr Hunaid Vohra told the hearing the outcome may have been different if he had been seen within the expected time.
Mr Ridley concluded the 71 year olds cause of death as "accidental".
He told the inquest: "He died as a consequence of a complication following surgery when he developed a bleed more likely than not from the surgical site."
Mrs Carpenter has previously told how her husband had said to her as they waited for the ambulance: "Where are they, I'm going to die".
"I just put my arm around him and said 'they're coming," she had said. "Just before 04:00 he said I feel faint but I could see he was slipping away from me and I rang them and shouted 'where are you, I'm losing him'.
"I was doing CPR and shouting 'don't leave me.'"
Describing her husband, Mrs Carpenter told the hearing: "Richard Carpenter was my husband of 47 years, my soulmate, and above all else, my best friend.
"Richard was a loving, kind, considerate, gregarious, and happy man who loved life.
"He had a lightning-fast wit and a wicked sense of humour. He was a gifted wordsmith, writing prose and poetry, sometimes saucy, but always with a sense of fun.
"He was an entrepreneur and managing director of his own successful marketing distribution and logistics company for over twenty years, with a portfolio full of blue-chip clients."
She continued: "At his funeral there were 125 in church that day including family, friends, and business colleagues from past and present.
"All the kind and sincere tributes they paid to him are too numerous to mention, that's how much he was loved, respected, and valued.
"After the service, the vicar said to us that never had she seen the church so full. Every pew was taken."
Speaking after the inquest, the 72 year old said she is pleased with the outcome of the inquest as she hopes it will impact the NHS.
She said: "I'm quite happy with what the coroner is going to do. The NHS needs shaking up."
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