A man died from sepsis which developed after he was forced to wait five months for kidney stone surgery.
David Curry, 77, should have undergone the operation within four weeks, according to NHS guidelines. But a lack of available operating theatres meant this target was missed.
An inquest into his death heard the long wait contributed to his death - as it meant a temporary stent was in much longer than planned, significantly increasing the risk of post-operation complications like sepsis.
The case has prompted Norfolk's most senior coroner to issue a warning to the new health secretary that similar cases will follow if waiting times are not cut.
Mr Curry, a retired carpenter, had first gone to the Norfolk and Norwich Hospital on April 7 last year when he was diagnosed with having a kidney stone.
He was fitted with a ureteric stent as an emergency procedure and referred for a ureteroscopy, a procedure which allows the stone to be removed.
This timescale stated he should have been listed for the surgery within a maximum of four weeks.
But five months later, Mr Curry, from Norwich, had still not been given a date for the operation and instead approached the city's private Spire Hospital, which carried out the surgery on September 20.
However, following the operation, Mr Curry developed sepsis and was transferred to the N&N where he died of multi-organ failure and urosepsis on October 1.
Following the inquest, which was held last month, senior coroner Jacqueline Lake concluded that he had died from "recognised risks of an appropriate procedure".
However, she said the risks were exacerbated by the length of time Mr Curry had been waiting for the procedure, prompting her to issue a Prevention of Future Deaths Report, which has been sent to Wes Streeting, the health secretary.
In it, she wrote: "Mr Curry required timely management.
"Evidence was heard that the risk of post operative urinary infections and sepsis is increased by prolonged stent dwell time.
"Due to a lack of theatre capacity, Mr Curry did not receive a date for the proposed procedure at the NHS trust for some five months following the initial procedure."
Spire Hospital in Norwich, where Mr Curry underwent his operation (Image: Archant)
Mr Streeting is now required to publish a formal response to Mrs Lake's report within 56 days.
A spokesman for the Department for Health and Social Care said: "Our deepest sympathies are with David's family and friends in this tragic case.
"Too many people are waiting too long for the care they deserve.
"This government will tackle waiting lists as we reform the broken NHS to ensure the health service is there for all of us when we need it."
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