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A coroner has recorded a narrative verdict on a man who died on his way to hospital after the ambulance in which he was travelling broke down.
Alfred Thresher, 73, from Clifton, Nottingham, died in June 2003 on his way to the Queen's Medical Centre.
An inquest shortly after Mr Thresher died recorded that his death was from natural causes.
But his widow was unhappy with the circumstances of her husband's death and won the right to a new inquest.
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He would still likely have died, but in hospital
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After recording the narrative verdict Dr Nigel Chapman said: "Alfred William Thresher died from natural disease.
"There was a delay in transferring Mr Thresher from his home to the hospital due to a breakdown of the ambulance's suspension.
"He would have survived to the hospital though he would likely still have died, but in hospital."
Maintenance review
Original post-mortem examinations showed Mr Thresher suffered from a lung disease known as cryptogenic fibrosing alveolitis.
In a statement after the first inquest, Mrs Thresher's lawyers had said when the natural causes verdict was recorded, the coroner was unaware of the ambulance delay.
It was later revealed in medical notes that there had been problems with the ambulance that had been "ongoing for some time".
The coroner has asked East Midlands Ambulance Service (EMAS) to review their maintenance policies.
The solicitor for EMAS, Lorna Hardman, said improvements have been made in the five years since Mr Thresher's death.
"We've significantly increased the numbers of crews and vehicles available.
The East Midlands Ambulance Service is now one of the top performing ambulance trusts in the country."
EMAS apologised to Mrs Thresher for the distress that was caused but has not formally accepted any blame.
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