A coroner has expressed concern over how an elderly man was taken to hospital after ambulance staff borrowed a chair from a supermarket when theirs failed to inflate.
Norfolk coroner Jacqueline Lake said a string of "matters for concern" which came to light during an inquest into the death of Robert Chandler was so serious other people could die.
Mr Chandler, 85, waited 50 minutes for an ambulance on September 24, 2018, after he suffered a collapsed lung (pneumothorax).
He died the next day in Gorleston's James Paget University Hospital.
An inquest into his death found he died of medical causes.
But the coroner was so concerned about some of the issues, she sent a prevention of future deaths report to the chief executive of the East of England Ambulance Service, saying equipment was not checked.
It has a legal duty to respond to the recommendations within 56 days.
Published on Sunday May 26 in the 'emergency services related deaths' category the report outlines "matters giving rise to concern" identified during Mr Chandler's inquest.
Mrs Lake said an inflatable chair intended to be used to lift Mr Chandler to the ambulance did not inflate properly so he was lifted underneath his arms and transferred to a chair borrowed from a local supermarket.
She said no pain relief was given and no safety straps were used.
Equipment, she said, should be checked by staff daily, adding: "The evidence is that this is not always done."
She also noted an electronic tablet was not sufficiently charged to record all the incident information, and that paper records were not adequately completed.
She said: "In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action.
"You are under a duty to respond to this report within 56 days of the date of this report.
"Your response must contain details of action taken or proposed to be taken, setting out the timetable for action.
"Otherwise you must explain why no action is proposed."
Mr Chandler's wife and son were also sent a copy of the report published on the Courts and Tribunals Judiciary website.
A spokesman for the east of England Ambulance Service said: "We would like to offer our sincere condolences to Mr Chandler's family.
"We have formally apologised to them for the delay in reaching Mr Chandler and for the distress they suffered during his treatment and transfer to hospital.
"Our Chief Executive provided a response to the Coroner and Mr Chandler's family regarding the Report to Prevent Future Deaths within the timescale given which addresses each of the points raised and, where appropriate, provides further explanation or details of actions being undertaken.
"This will be published by the Coroner in due course."
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