Assistant Cornwall coroner Guy Davies has written to Health Secretary Victoria Atkins to raise concerns about the deaths of Patricia van der Eyken and 86-year-old Robert Prowse.

Ms Van der Eyken, aged 93 of Chacewater, near Truro, and Mr Prowse, aged 86, from Penzance, died on September 13 and 19 last year respectively.

Both cases were classes as Category Two when ambulances were called which means the maximum response time target is 18 minutes with 90 per cent of cases being reached within 40 minutes.

Ms Van der Eyken died at her home after a delay of two hours 37 minutes and Mr Prowse died at hospital after a three hour, 47 minute wait for an ambulance which was followed by another 85 minutes at The Royal Cornwall Hospital, Treliske.

The assistant coroner has written Prevention of Future Deaths reports in both cases which describe the failings of the ambulance service in Cornwall as systemic but which also identifies a chain of problems arising from inadequate social care provision.

Mr Davies points to patients being unable to leave hospital when they are well enough to do so, which adds to congestion in the hospital and cascades on to congestion in A&E and leads to ambulances being unable to drop off patients.

He said in 2023 the South Western Ambulance NHS Trust lost 35,583 hours in handovers at the Royal Cornwall Hospital,- the county's main hospital, and 53,080 hours at neighbouring Derriford Hospital in Plymouth, Devon. They are two of the worst affected hospitals in the country.

Both hospitals have seen dozens of ambulances queuing up outside A&E departments with patients as the hospitals try to care for sick people in corridors.

In his letter to the Health Secretary, Mr Davies said: “In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action.”

He gave her 56 days to respond with proposals of how the problems can be alleviated.

The two reports highlighted the circumstances around the two deaths.

Robert Prowse was suffering from dementia. In the early hours of September 19th last year a neighbour called 999 and said Robert was breathing but not conscious and may have had a seizure.

The South West Ambulance Service determined a Category 2 response but an ambulance did not arrive for three hours and 47 minutes from the original 999 call.

When it got to the Royal Cornwall Hospital, the patient could not be transferred because there was no space in the A&E department, which was crowded with patients being placed in corridors.

Robert was taken to a triage centre in a car park where he showed signs of sepsis but his condition was not deemed to be immediately life threatening and he was returned to an ambulance parked outside A&E.

He stayed in the ambulance for another 85 minutes rather than the 15 minute handover target to A&E.

But sepsis was found and he died two hours later before prescribed antibiotics could be administered.

South West ambulance data showed handover delays at the Royal Cornwall Hospital cost the service 2,981 hours or 271 ambulance crew shifts - and at Plymouth's Derriford Hospital 6,359 hours - or 581 ambulance crew shifts in just September 2023.

Mr Davies said that 'fit and well' Ms van der Eyken died on September 13. She dialled 999 saying she was having a heart attack and an ambulance took two hours and 37 minutes to get to her home and she was found dead by the 999 crew at her home.

A spokesperson for Cornwall and Isles of Scilly Integrated Care System, said: “Our sincere condolences go to the families of Mr Prowse and Ms Van der Eyken, we take every coroner’s report seriously as behind these statistics are people and families who have been affected, and we are profoundly sorry for their loss.

“We are working closely with health and care partners across Cornwall and the Isles of Scilly to identify and respond to the concerns raised in this report. We want to put into place local arrangements that ensure we continually improve our services with quality and patient safety at the heart.

“We are also addressing the complex issues highlighted in the coroner’s report to reduce waiting times, hospital admissions and increase hospital discharges, by providing more care and treatment locally.”