A man who phoned for an ambulance while having a heart attack in a supermarket car park was discovered dead by paramedics when they eventually arrived, five hours later.
The body of Martin Coleman was found in his van outside Lidl in Taverham in the early hours of July 1 last year. He was 54.
His death - just a 15-minute drive from Norfolk's biggest hospital - highlights the extraordinary pressures facing the region's ambulance service.
Ambulance queued outside of the Norfolk and Norwich University Hospital (Image: Archant)
An inquest held this week heard that Mr Coleman, a handyman from Reepham, had pulled over into the car park at around 10.15pm after being overcome with chest pains and heart palpitations while driving.
He phoned for an ambulance telling a call handler: "I think I am having a heart attack".
At the time, the service was on 'black alert' due to the acute pressures it was facing and no ambulances were available when he called.
He was told to keep his phone line free, so did not contact friends and family. The car park is around a 15-minute drive from the Norfolk and Norwich University Hospital.
When a call handler phoned him back at around 11.15pm, there was no answer from Mr Coleman.
It was not until after 3.30am that paramedics arrived, and found him dead inside the vehicle.
The inquest heard his call had been picked up by a handler in Newcastle as part of an arrangement between trusts to help deal with demand at busy times and was correctly prioritised as a 'category two' call.
These are the second most urgent type of calls, which include heart attacks, and should be responded to in no more than 40 minutes - with a target of 18 minutes.
At 10.29pm, the call handler told Mr Coleman an ambulance would be on its way and instructed him to make himself comfortable and to keep his phone line free.
Mr Coleman was able to climb out of his vehicle, recline the passenger seat and get back in to lie down and wait for the ambulance to arrive.
But by the time it reached the Fir Covert Road car park, at 3.40am, he was already dead.
His daughter, Roxanne, told the inquest: "My dad was a strong, proud man who would only call for an ambulance if he really needed it.
"I loved him more than life itself. I greatly admired his desire to help anybody.
"He was so much more than a father and a grandfather. He is not going to be a statistic, he is a human being who is missed and loved more than anything."
Chris Hewitson, patient safety manager at the East of England Ambulance Service, told the court that at the time of Mr Coleman's call the service did not have a single ambulance free to attend, nor were there any community first responders available.
Mr Coleman's daughter questioned why her father's call was not escalated when he did not answer the attempted 'callback' around an hour after his original one.
She asked whether callers could be asked to provide an alternative contact number -such as a next of kin - when making an emergency call on their own.
Mr Hewitson said this was not something that was currently done, but could be considered.
Meanwhile, David Allen, head of operations at EEAST, highlighted the pressures the service continues to face - despite efforts to make improvements.
He said: "Sometimes we can have up to 30 ambulances waiting outside the Norfolk and Norwich [hospital] at any one time.
"There are over 400 patients across the three Norfolk hospitals who are medically fit to leave but cannot be discharged."
He said the ambulance trust was making efforts to treat more people in the community and had been able to reduce the number needing hospital admission by 22pc.
Yvonne Blake, area coroner for Norfolk, concluded that Mr Coleman had died of a heart attack - but that she could not give a precise time of his death.
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