A grandfather was left dying in his home while a paramedic waited outside for 16 minutes as he carried out a health and safety assessment.
The family of Roy Adams believe he might have survived if those 'vital minutes' had not been squandered.
The 61-year-old police chauffeur, who suffered a suspected heart attack, did finally receive treatment, but died on the way to hospital after suffering breathing difficulties.
Mr Adams telephoned 999 from his home in Morden, south London, complaining of chest problems.
On the advice of the operator, he left both the communal door to the block of flats and the door to his own apartment on the latch to enable the ambulance crew to get in quickly.
But when the rapid response medic arrived six minutes later he decided against going straight into Mr Adams's home.
It is believed that, because the doors were open, he feared that the flat was being burgled.
Instead the medic carried out an on scene risk assessment and called the police for back up.
After waiting for 16 minutes he went into the property to find Mr Adams - who was alone in the property - dying on the floor unable to breathe.
He was taken to hospital but died before he arrived.