Stewart Maltby inquest: 'Repeated failures' in care
An inquest concluded that a man died after there were "repeated and systematic failures" by ambulance and hospital staff.
Stewart Maltby, 64, from Farnsfield, Nottinghamshire died from kidney failure in November 2012.
He waited five hours for an ambulance when taken ill and 14 hours for fluids after he reached hospital.
Nottingham coroner Jane Gillespie said there were "serious failures" in his care and recorded a narrative verdict.
Mr Maltby was taken ill on 5 November and his GP requested an ambulance be sent within two hours.Staff 'oblivious'
But, owing to an administrative mistake, the call was not prioritised and the ambulance took nearly five hours.
When he arrived at the Queen's Medical Centre in Nottingham, Mr Maltby was not given the correct fluids for almost 14 hours.
Miss Gillespie said that owing to staff being overworked, they were "oblivious" to his deterioration.
The family's solicitor, Paul Balen, said: "We have learned that Stewart was not the first patient to die on this ward as a result of poor management, lack of staff, defective procedures and lack of action at the time.
He added: "It is fairly easy to see how [improvements] can happen with the ambulance service.
"But the jury must still be out with the hospitals because everyone knows hospitals, and their staff, are under enormous pressure and it's only human nature that at some stage something has to give."
He said it was "highly likely" the family would now take some form of legal action.
Peter Homa, chief executive of Nottingham University Hospitals NHS Trust, said: "We have learnt from this sad and tragic case and made changes to improve safety and outcomes for our future patients.
"We have closely monitored the implementation of each of the investigation's recommendations at the highest level and have shared our learning with the ward concerned and trust-wide."
A spokesman for East Midlands Ambulance Service said they had changed their computer system and issued guidelines for control centre staff to ensure the error is not repeated.