The family of a Fairbourne pensioner who died in agony after he was made to wait in an ambulance outside hospital for eight hours, say this must never be allowed to happen again.

At an inquest into the death of retired shopkeeper Peter Connelly, who died at Wrexham Maelor Hospital on 20 February, 2018, Mr Connelly’s brother John said the family did not want others to have to go through the same harrowing experience.

“After 20 months what has changed?” he asked.

The inquest heard how Peter Connelly, 70, of Ffordd Meirion, Fairbourne had arrived in an ambulance at the hospital at 2.15pm on 19 February.

With up to nine ambulances queuing outside the emergency department on what staff described as “a challenging night” he was not admitted until 10pm, by which time his condition had deteriorated.

He died the following afternoon of multi-organ failure due to acute pancreatitis caused by gallstones.

The inquest at Ruthin heard how he had been in excruciating pain and crying “Please help me”.

Professor Solomon Almond, who was called as an independent expert, said that even if Mr Connelly had been admitted to hospital immediately the outcome would probably have been the same.

But he said: “If the delay had been 20 to 30 minutes then so be it, but for it to be any number of hours cannot be right. Eight or nine hours is too much.”

The way in which the seriously ill pensioner was kept in an ambulance outside hospital for eight hours has been described as “unacceptable” by the heads of two major health bodies.

Jason Killens, chief executive of the Welsh Ambulance Services Trust (WAST), and Gary Doherty, his counterpart with the Betsi Cadwaladr University Health Board, gave evidence at the inquest.

Both Mr Killens and Mr Doherty, along with operational staff from both organisations, told John Gittins, coroner for North Wales East and Central, that numerous steps had been taken to tackle the problem of ambulance handover times, including reducing the number of patients needing hospital care and improving triage systems, and the measures were proving effective.

When faced with queuing ambulances and a long wait, Mr Connelly’s family asked if he could be taken to another hospital instead.

They were told that once an ambulance had entered the hospital grounds that could not be done, but now Mr Killens said talks were being held over diverting ambulances from hospitals where there were long queues.

Mr Doherty said there were definite improvements and further measures were planned, adding: “It is less likely to happen.”

Expressing condolences to the family, he said: “It should not have happened.”

Recording a conclusion of natural causes, Mr Gittins said that, while it was clear that the situation had improved and the latest figures were encouraging, he still had enough concern about staffing issues, patient flow and handovers to issue a Regulation 28 report to the health board about the risk of future deaths.

The report will not go to the Ambulance Trust.

Thanking Mr Connelly’s family for the manner in which they had conducted themselves throughout the hearing, the coroner said: “You have afforded this process the dignity which Peter was denied in the ambulance that night.”

After the hearing a spokeswoman for the health board apologised.

“We offer our full and sincere apologies to Mr Connelly’s family,” the health board spokesperson said.

“The delay he experienced outside our emergency department was and remains unacceptable.

“Our performance on ambulance transfers has improved over the last 12 months, and we will continue to work with our partners to make further progress and provide safer care.”