Slow Welsh ambulance times failed Pontypridd men
The ambulance service has been accused of systemic failure after two cases of not reaching emergencies on time despite available vehicles.
The 999 calls were made in Pontypridd but although there were no free ambulances there, available help from outside the area was not sent.
Both men died in hospital but no direct link to the ambulance response time was made.
The ambulance service said improvements were needed.
One of the men waited for two hours and 45 minutes and the other for 51 minutes.
Peter Tyndall, the public services ombudsman for Wales, has made nine recommendations, including telling the Welsh Ambulance Service NHS Trust to review the way ambulances were dispatched.
He said he had reservations about the manner in which the trust provided its services to patients.
He also told the trust to apologise to the families of the men, who have not been identified, and to pay them £2,000 each in redress for the "woefully inadequate" manner it dealt with their subsequent complaints.
Mr Tyndall's report states the daughter of the first man phoned 999 at 23:10 on the evening of 27 June 2009 after he fell at home.
Just over an hour later she called again saying his condition was worsening and, during a third call at 00:56, she said he was having difficulty breathing and passing in and out of consciousness.
Two more calls were made before an ambulance arrived at 01:57.
Later that day he underwent a hip replacement operation but died four days later of heart failure.
An investigation found up to 11 different emergency vehicles could have been sent during the time he was waiting.
The second man started experiencing breathing difficulties early on 19 July 2010 and his wife dialled 999 ay 06:09.
An emergency ambulance became available 37 minutes later but needed to change oxygen cylinders and did not arrive until 07:00.
He died three hours later from what his family was told was a heart attack. They believe the delay affected his health.
Again response vehicles from outside the divisional area were available.
In his report, Mr Tyndall said: "I have ongoing reservations about the manner in which the trust provides its services to patients.
"Clearly the trust has now recognised failures to identify out-of-area resources and reminders have been issued to the staff involved.
"However, I am more concerned that this failure to look outside divisional boundaries is representative of a wider organisational culture of operating within divisional boundaries."
The Welsh ambulance service said it extended its "deepest and sincerest apologies" to both families involved in the cases.
A spokesperson added: "The trust has developed detailed plans to address the recommendations outlined, of which an initial response has been provided to the ombudsman.
"The trust recognises the improvements it is required to make and is committed... to deliver high quality and clinically safe services for patients across Wales in partnership with health boards.
"The way in which the trust responds to incidents has and is being developed further to ensure every effort is made to respond to the most serious and life threatening cases first.
"We take all complaints we receive extremely seriously and are making continuous improvements to our internal complaints procedures to make sure that anyone who contacts the Welsh ambulance service receives a timely and comprehensive response."