Mr Hawkins, from Rhyl, arrived at hospital at 1:25pm on March 18 and remained in the ambulance until 11:42pm, at which time he was placed in the corridor of the Emergency Department at Glan Clwyd Hospital in Wales.
He was finally allocated a bed at 7:17pm two days later, on March 20, according to an NHS North Wales prevention of future deaths report.
Despite the veteran’s cause of death being recorded as an accident, David Pojur, assistant coroner for East and Central North Wales, said there was no space in the emergency department for a nurse to assess or treat the retiree.
His “repeat bloods” had not been done, he had been fed by visitors who had not been told he was “nothing by mouth”, and the hospital was understaffed.
In the report sent to the Betsi Cadwaladr University Health Board and Welsh Ambulance Service, the coroner said: “I am concerned about the wait Mr Hawkins endured to be admitted to hospital and about the provision of a bed, the inability of staff to care for him, the lack of available staff and the lack of a written record of assessment and treatment.”
Several recent reports of preventing future deaths have highlighted the NHS crisis in North Wales, with elderly patients dying after long delays in ambulance arrivals and lengthy waits outside hospital emergency units.
Hawkins’ death prompted calls for Welsh Prime Minister Mark Drakeford to resign.