A 39-year-old Shepway man brought in a critical condition to Maidstone Hospital did not receive treatment for more than five hours, a coroner heard.

Matthew Crowley was rushed by ambulance to A&E with a lump in his groin the size of a grapefruit on June 9 last year.

He was pale, jaundiced, septic and heading into multiple organ failure.

He died the following day after his transfer to Tunbridge Wells Hospital at Pembury.

An inquest at Archbishop's Palace in Maidstone heard how the Northumberland Road resident was a heroin user known to take the hard drug intravenously.

In the days before his death Mr Crowley had also complained of pain in his left leg.

But the court heard despite the unemployed man's serious condition staff a doctor's assessment was not carried out until hours later because of a shortage of staff and a high level of demand.

Because of these factors the doctor responsible had discontinued the trust's rapid access to treatment protocol, which requires patients brought in by ambulance to be triaged within 30 minutes of arrival.

Complications arising from his condition prevented doctors from beginning IV a treatment of fluids and antibiotics until about 10pm – around five hours after admission that evening.

Mr Crowley needed specialist care that required his transfer to another hospital but requests were refused by St Thomas' Hospital and Medway Maritime.

Eventually he was transferred to Tunbridge Wells Hospital- 11 hours after his admission to A&E. Within two hours he went into arrest and attempts to revive him failed.

The postmortem was carried out by Dr David Rouse, an independent pathologist. He gave a medical cause of death on June 10 last year as sepsis linked to a leaking hole in his left thigh and intravenous drug abuse.

"It’s unfortunate this led to the tragic loss of my brother. However it is important people continue to trust in hospitals and don’t just focus on when things go wrong" - Christian Crowley

Summing up senior coroner Patricia Harding said there had been "lamentable and unnecessary delays" in Mr Crowley's care.

She recorded a narrative verdict and made a regulation 28 report to MTW's chief executive Glenn Douglas with a catalogue of issues to be addressed to prevent similar deaths in the future.

These include the fact that protocol capping the wait for patients brought in by ambulance had been discontinued due to pressure on emergency care and the two-hour and 20-minute delay before Mr Crowley was assessed by a senior doctor. T

The intensive care unit at Tunbridge Wells Hospital at Pembury were not informed of the transfer.

Patricia Harding said she would require the trust to respond by April 15 this year with details of action taken.

She said: “Significant though these delays were, it cannot be said on the balance of probabilities that had they not occurred Mr Crowley would not have died.”

A spokesperson for MTW said an internal investigation had identified said the coroner had identified similar changes. They said: “We welcome every opportunity for learning, and are committed to fully completing the implementation of the changes necessary to ensure that we provide the highest standards of patient care."

Matthew Crowley’s brother Christian said: “It’s unfortunate this led to the tragic loss of my brother. However it is important people continue to trust in hospitals and don’t just focus on when things go wrong.

“They save thousands of lives every day.”