A patient died because so many ambulances were stuck outside a hospital that nobody could respond to their 999 call.
Not one ambulance from Cromer to Waveney - a distance of almost 50 miles - was free, meaning the woman had to wait an hour for a crew to come from Ipswich last month.
By that time, they had died, according to papers which go before bosses at the East of England Ambulance Trust (EEAST) on Wednesday.
The 999 call - from the Waveney area - was classed as the most urgent, meaning a crew was meant to be on the scene in eight minutes.
However, nine ambulances were stuck at the James Paget University Hospital in Gorleston waiting to unload other patients.
The ambulances were delayed at the hospital for more than five hours, the papers show.
A lack of space in hospitals has led to long delays across the region for ambulances to handover patients and crews warned last month that it was costing lives.
Figures obtained by this newspaper also reveal that ambulances were delayed outside Norfolk hospitals for at least an hour for a record 2,200 times in September.
In another case a 66-year-old man who had a punctured lung lay on his kitchen floor for six hours, waiting for an ambulance.
Meanwhile, one stroke patient waited nine hours for a vehicle while his wife called 999 six times. They have complained that the delay made his condition worse.
Waveney's Conservative MP Peter Aldous said he would raise the cases and issue of handover delays with the hospital, EEAST and Norfolk and Waveney's NHS.
"In the past problems have been focused on the NNUH but it has extended across the patch which is a matter of serious concern and new measures need to be put in place," he said.
Board papers show EEAST received 150 complaints in October about delays - up 66pc from September.
They warn: “There is the likelihood of avoidable harm continuing throughout the winter period.”
EEAST chief executive Tom Abell said more than 12,000 hours of ambulance time was lost in October due to ambulances queuing outside of hospitals for longer than 15 minutes.
He wrote he was “concerned and distressed… at the impact that this current situation is having on our ability to deliver the standard of care".
He added: "I am extremely sorry to those patients, families and colleagues which have been affected.”
Delays are being caused initially when ambulance crews check-in patients to A&E, according to one source, because there aren’t enough nurses on duty.
There is then a delay while they wait for a bed to become free at A&E for that patient.
“A&E is chronically understaffed, especially at the NNUH,” they said. “The staff have hundreds of other things to do so there are always delays handing over.”
To tackle this, EEAST said it was providing health care assistants to look after patients at hospitals, which would mean ambulance crews could get away. Mr Abell also said they were introducing a “rapid drop off system” for life-threatening emergencies.
Meanwhile a spokesman for the NHS in Norfolk and Waveney said NNUH's emergency department was being redesigned to increase capacity, while a senior clinician at the front door would also help with assessment and reduce "inappropriate" attendances.
On almost 1,200 occasions in September it took ambulances more than an hour to drop off a patient and go to their next emergency call at the NNUH. That figure is up 230pc in a year, according to a Freedom of Information request from this newspaper.
Last month NHS England bosses wrote to hospitals telling them to stop using ambulances as "additional emergency department cubicles". They wrote after two patients died in ambulances in hospital car parks in the region.
But so far that call appears to have had little effect. Sources have told this newspaper that they are having to wait up several hours at the NNUH.
At the Queen Elizabeth Hospital in King’s Lynn ambulances were delayed by more than an hour for a record 500 times in September, with the same figure at the James Paget.
At West Suffolk it was 179, similar to last winter.
Separate figures show one in three ambulances were delayed at NNUH in September by more than 15 minutes.
A spokesman for the NHS in Norfolk and Waveney said: "We are working collaboratively with the ambulance service to keep patients safe during busy periods and to prioritise patients according to clinical need."
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