A coroner has pleaded with the HSE to review their protocols for ambulance turnaround times at hospitals across the country.
It comes after the inquest into the death of Co Donegal mother-of-eight who died in the early hours of January 9, 2018.
The inquest at Letterkenny Coroner’s Court heard how it took an ambulance 71 minutes from Letterkenny University Hospital to reach Margaret Callaghan at her home just 2km away.
Mrs Callaghan (71), from Bracken Lea, at Mountaintop, in Letterkenny, had only been released from hospital the previous day having undergone a non- emergency bone marrow biopsy.
However, her daughter Caoimhe told the court her mother gradually got worse as the day went on.
She was tired and frail and at 5.20am the family called an ambulance as their concerns for their mother increased.
They were forced to call the 999 service three times as the ambulance was delayed and the ambulance did not eventually arrive until 6.31am.
The paramedics tried to work on Mrs Callaghan but she was later pronounced dead at the scene.
The court was told two ambulances parked at the hospital had been having off-load delay issues because of a capacity issue at the hospital and they could not release their patients into the care of hospital staff.
One ambulance was queuing at the hospital for six and a half hours while the other had been there for three and half hours.
An ambulance which had been in Dungloe, which is 58km away, was dispatched to attend Mrs Callaghan but that was stood down when one of the ambulances was eventually freed up.
Professor Cathal O Domhnaill, medical director of the National Ambulance Service said the issue of off-load times with ambulance around the country was endemic.
He added these delays are a consequence of emergency department overcrowding and that overall hospital capacity is the issue.
He further said the issue in his opinion has gotten worse in recent times.
General manager of Letterkenny University Hospital, Sean Murphy, painted a grim picture of conditions at the hospital.
He revealed that full capacity protocol at the hospital was in place during 94pc of the time during this past year.
He described the situation as “horrendous” but paid tribute to his staff for the conditions in which they had to work on a daily basis.
He said even with the opening of an extra 10 beds in the past year as well as a ‘discharge lounge’ they were still fighting over-crowding on a daily basis.
He described how he and his director of nursing recently went around the hospital in the middle of the night looking for extra bed capacity because of overcrowding.
Sean Magee, barrister for the Callaghan family asked if an extra trolley could be placed on an ambulance so that it could be used to prevent or relieve off-load delays.
But Mr O Domhnaill said this could not be possible for a number of reasons including the fact that ambulance simply could not fit it in.
Coroner Dr Denis McCauley said he was returning a narrative verdict that Mrs Callaghan had died as a result of haemorragic shock as a result of haemorrhage secondary to a bone marrow biopsy.
He then called on the HSE to review those protocols for the prevention of ambulance delays because the present ones are “insufficient and unworkable.”
He expressed sympathy with the many members of the extended Callaghan family who were present for the inquest.