A coroner has warned of the potential for future deaths after a 95-year-old woman died after waiting almost four hours in an ambulance queue outside a hospital.
Lilly Baxandall, 95, a former British Airways catering supervisor, could not be admitted to Glan Clwyd Hospital, Bodelwyddan, North Wales, which at one point had 13 ambulances parked up unable to admit patients, Ruthin Coroner's Court heard.
While expert witness evidence said her death was not caused by the delay in her admission, John Gittins, Coroner for North Wales East and Central said the problem of ambulances waiting outside hospitals due to bed blocking should not be allowed to become "the norm".
He added: "There's a very real and significant danger future deaths will occur and there's a danger of potential culpability that goes beyond concerns I recognise, be they of a civil or criminal nature, in terms of gross negligence manslaughter."
Glan Clwyd Hospital, which is in special measures, was put on "red alert" when Miss Baxandall was admitted, because it did not have enough beds and staff to treat patients and two neighbouring hospitals that would normally help were also struggling to cope, the inquest heard.
The spinster, who drove ambulances in the Second World War before working in London and retiring to North Wales, fell at her Abergele bungalow on September 1 2014, which caused a deep clot on her brain.
An ambulance was called to take her to hospital, arriving at Glan Clwyd at 5.26pm.
Her great-niece, Kate Thomas, herself a local hospital doctor, rushed to the hospital.
As they waited in the ambulance, a nurse told them not to expect to be admitted "any time soon" and Miss Baxandall responded: "Just as long as I don't end up on the news."
When Dr Thomas returned to hospital later her great aunt was already in the resuscitation unit and it was "too late" to save her.
Miss Baxandall had remained in the ambulance under observation but her condition deteriorated around 8pm and she lost consciousness.
A doctor arrived at 8.10pm then left to arrange a CT scan but he returned soon after and at 9.05pm she was finally taken into the hospital straight to resuscitation.
She died four days later, the coroner recording an accidental death due to the brain bleed and pneumonia caused by the head injury in her fall.
Dr Geoffrey Phillips, a consultant geriatrician who compiled an independent expert report on Miss Baxandall's death, said earlier intervention and treatment would not have made much difference.
He said: "I think, sadly, this lady was doomed from the moment she had a head injury.
"Had everything been done much earlier, she would not have died how and when she died, but on the balance of probabilities I think she would have cursed us for putting her in a nursing home."
Matron Frances Millar was on-call and in charge of "escalation" as the crisis deepened on the night Miss Baxandall was admitted.
She said there were not enough staff and there was a lack of beds with her walking round the hospital four times looking for space to admit patients.
Betsi Cadwaladr health board, which runs the hospital along with Maelor Hospital in Wrexham and Ysbyty Gwynedd in Bangor, has been put in special measures since 2015.
The inquest heard ambulance delays "have not gone away" and on Monday seven patients were stuck in ambulances for more than an hour outside Glan Clwyd with 37 patients "bed blocking" and unable to be discharged.
A further "red alert" situation had also occurred within the last month.
Gary Doherty, chief executive of the health board, said: "I think we are improving, but we have a long way to go."
The coroner said he would write to the Welsh Assembly, the health board, the Welsh Ambulance Service and the four local authorities in North Wales for a joint response on tackling issues of "timely" hospital admissions, the discharge of patients and social care and resources for the ambulance service.
Copyright (c) Press Association Ltd. 2017, All Rights Reserved. Picture (c) Peter Byrne / PA Wire.