Galway Girl Ed Sheeran
A crew working for our regional ambulance service, the East of England ambulance Trust, which left a body on the floor so they could finish their shift on time were told it was "common practice" and had happened before, an inquest has heard.
James Harrison, 32, collapsed and died in a street in Cambridgeshire in the early hours of September 24.
The crew - who were due to finish their night shift at 6am - arrived at the scene in Littleport at 5.30am after he was found by a milkman but were unable to save him, an inquest in Chatteris heard.
Instead of extending their 15 hour shift to transport the body to the mortuary at Addenbrooke's hospital, they took him to nearby Ely ambulance station and left the body to be collected by an undertaker.
The undertaker never arrived and it was not until after 8am that another ambulance crew was sent to take him to hospital.
Opening the inquest, coroner William Morris rejected an application from lawyers for the East of England Ambulance Service to restrict the inquest to the death itself and not the circumstances which followed.
He said it was in the public interest to consider the "indignity, distress and possibility of forensic evidence being compromised" by the delays.
Mr Morris concluded that Mr Harrison died in an accident as the result of taking a cocktail of prescribed anti-depressants and insomnia medication.
Paramedic Steve Hibbitt, who investigated the incident, said crews in that area had failed to take bodies straight to hospital on seven previous occasions.
On two occasions bodies had been left on the floor and on five occasions in the back of an ambulance.
The inquest heard paramedics David Glenton and Ann-Marie Poole attended the incident along with first responder Dharamendra Narotam.
Mr Harrison was pronounced dead at 5.53am - just before Mr Glenton and Ms Poole were due to finish their shift.
Despite the fact they were already working overtime, the pair said they were happy to transport the body to hospital, Mr Hibbitt said.
But Mr Narotam suggested the body could be left at the ambulance station and collected later.
Mr Glenton did not question this decision.
He told the inquest: "He made it sound like it was common practice."
Mr Hibbitt added: "The crew were not familiar with this procedure but were advised it was a normal local practice and several bodies had been left in this way before. The responder did not feel he was doing anything inappropriate and that he was doing something respectful by covering him in clean sheets."
He explained it was not ambulance service policy to do this but it was not uncommon for local crews to follow different and sometimes outdated procedures which also depend on police and coroner's practices.
"This may be due to lack of knowledge of accepted practice but may also be due to staff taking short cuts" he said.
Mr Narotam said he had not seen anything wrong with the approach at the time.
He said: "I mentioned that in the past we had removed the body from public gaze to the ambulance station without any problems. It was agreed with police at the scene."
Mr Harrison's family were not informed about the incident until it was reported by the press when a whistle-blower claimed the body had been left by bins at the station.
Mother Diane Harrison said she knew her son was on prescribed medication.
She added: "I was extremely shocked to learn he was dead. He would have not have done this on purpose, he would not have left me on my own."
Tracy Nicholls, director of clinical quality at the East of England Ambulance Service, said: "We apologise wholeheartedly to the family for the distress this incident has caused - it should never have happened.
The trust has carried out a full investigation into this matter and it is clear that incorrect decisions were made and the trust's procedures were not followed.
As a result of this we immediately sent out an instruction to staff that such a practice is not acceptable and must not happen."
The members of staff involved are subject to an ongoing investigation, she added.