The ongoing pressures on Cornwall's health service have once again come to the fore after an inquest heard how a retired Army colonel did not receive the treatment that may have saved his life because he was forced to wait in the back of an ambulance outside A&E for more than five hours before being admitted inside.

Col John Codd, who was known as Bill, had been a fit man until December last year when he started suffering from recurrent urinary problems and chest infections and his health took a turn for the worse.

The hearing into the 88-year-old's death held in Truro today (Monday, July 27) heard how Bill had been staying at the Trevarna residential nursing home in Carlyon Bay, outside St Austell, while arrangements were being made for him to go and live with his daughter Leaf Winter in Axminster.

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On January 16, Bill had been returning to the nursing home from a GP appointment when he stepped out of his taxi and fell backwards onto his right side and suffered an injury to the pelvis area. A very rare massive hematoma developed in his abdomen area made worse by the blood thinning medication Bill had been on to deal with a separate condition.

The inquest heard how an ambulance took just over two hours to arrive at a time when South Western Ambulance Service NHS Trust said it was under 'severe' pressure.

However, the inquest also heard that because of handover delays at the Royal Cornwall Hospital in Truro, Bill spent a further five hours and 40 minutes in an ambulance before being admitted to the emergency department.

Andrew Cox, senior coroner for Cornwall and the Isles of Scilly, who has previously written two Prevention of Future Deaths reports (PFD) to the Secretary of State for Health and Social Care, said the challenges Treliske and the ambulance trust faced at the time of Bill's death were "systemic in nature" and "the problem is too big for any single doctor, nurse or paramedic to fix on their own", adding that it is not a new problem.

The inquest heard that at the time of Bill's death, the RCHT was under immense pressure and more than 27,000 hours had been lost due to handover delays, which equated to the A&E department working at full capacity 24/7 being shut down for several weeks.

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While the situation has improved, Dr Aaron Green from the Trust told the inquest that in June, 16,200 hours had still been lost to those systemic pressures. He told the hearing that had Bill been admitted sooner into A&E it was probable that his massive hematoma would have been spotted sooner and it is possible that blood transfusion treatment might have been administered sooner.

He told the inquest: "If the system was not so crowded and working perfectly, Bill would have seen a doctor within 60 minutes and we would have identified the need for a CT scan that would have shown evidence of the hematoma. It is not certain it would have shown but it may have given us an opportunity to deal with it.

"Bill would have received a blood transfusion. It is possible, not probable, that an early transfusion could have prevented his death."

Mr Cox said the systemic issues impacting the NHS in Cornwall and the rest of the country warranted him writing another PFD report to the new Labour Government to highlight such problems.

He said at the time of Bill's death every hospital and ambulance trust in England had declared a critical incident with medically fit patients not being able to be discharged, ambulances being stacked up outside emergency departments up and down the country and not being on the road doing their job.

In a narrative conclusion, Mr Cox said Bill had been fit and healthy until the end of December last year when he developed some health issues. He said that while the ambulance arrival delay did not directly contribute to Bill's death after his fall, waiting for hours in the back of an ambulance to be moved into the hospital was a contributory factor.

He added: "If Bill had been admitted to Treliske earlier it is probable that he would have had an x-ray sooner and a CT scan would have been ordered earlier. It is possible that if a blood transfusion had taken place his death would not have happened when it did."