A coroner has warned health chiefs after an 88-year-old died after being forced to wait more than eight hours for an ambulance.
Anton Kusz, from Bridgend, broke his hip in January and died two days later of a cardiac arrest.
Coroner Andrew Barkley told the Welsh Ambulance Service and Abertawe Bro Morgannwg Health Board "action should be taken to prevent future deaths".
Both said they were working to improve their services.
Mr Barkley, senior coroner for south Wales central, recorded a narrative conclusion at an inquest into Mr Kusz's death in April.
A report published on Wednesday said the initial 999 call was chased at least seven times before it was made more urgent by the ambulance service.
The first call was made at 08:22 on 5 January after Mr Kusz had fallen in his Bridgend care home and had to lie on the floor as he waited for the ambulance.
Five hours later, Mr Kusz was seen by his GP, who found he had an occasional irregular heartbeat and asked for an urgent ambulance.
The report said it was not until 14:47 that an ambulance service clinician carried out a review and escalated its status, but did not say what time the ambulance finally arrived.
Mr Kusz was taken to the Princess of Wales Hospital in Bridgend, where he had hip surgery the following day and died a day later.
Mr Barkley said the inquest found one of the main reasons for the delay was the lack of ambulances, caused by "extensive delays" of up to four hours at hospitals across the region in handing over patients at accident and emergency departments.
He wrote it was not clear whether the delay directly led to Mr Kusz's death.
He said: "The fact that an 88-year-old gentleman with a serious injury such as a fractured hip had to remain on the floor in the same position in pain for over eight hours raises a real concern for the safety of others."
Mr Kusz's daughter, Manuela Hiett, said the ambulance service needed to change the way it operated.
"I don't think consideration was afforded to his age and the time he was left on the floor," she said. "They had a doctor at the home who said he needed an ambulance."
The Welsh Ambulance Services NHS Trust said: "We apologise for the unacceptable delays he experienced in his care and have been working closely with our colleagues at Abertawe Bro Morgannwg University Health Board to address the concerns which the coroner raised."
A spokeswoman for the health board said its services were experiencing an "exceptionally busy period" at the time of Mr Kusz's death.
"We saw an increase in the number of patients arriving at our hospitals and in particular within the first three weeks of January 2017 an increase of 32% in the number of ambulances arriving with the most urgent category of patients," she said.
"We regularly review our plans for dealing with increasing levels of demand on our services and the coroner's report has assisted us to further develop and improve them."