Institutional "failings" led to a man being taken by ambulance to the wrong hospital for his condition, a doctor has told an inquest.
James May, 76, died at the James Paget Hospital, Gorleston, Norfolk, in September 2013.
Dr Ranjith Ganepola said Mr May had been taken by ambulance to the hospital that night with heart problems.
He said if Mr May had been taken to the Norfolk and Norwich University Hospital he might have lived.
An inquest heard the Norfolk and Norwich University Hospital was the best for treating people with heart problems out of hours after specialist staffing levels were reduced at the James Paget Hospital in about 2007.
James Paget Hospital had specialist cardiology staffing levels reduced several years ago
But the East of England Ambulance Service decided Mr May's heart problems were not so serious that treatment at the Norfolk and Norwich hospital was necessary and the James Paget hospital was nearer, the inquest was told.
Dr Ganepola told the inquest he believed the on-duty senior consultant Dr Syed Zaid had been asked to attend the hospital that night, when staff had to deal with two people with serious heart problems - who both died - but that he had decided not to.
This was denied by Dr Zaid, who told the inquest in Norwich he had not been asked to attend the hospital that night.
Dr Ganepola said: "They (the hospital managers) have not dealt with the institutional failings of the James Paget Hospital; where senior medical personnel who should have attended a patient did not attend; where junior doctors did not ask for help.
"If he had gone to the Norfolk and Norwich University Hospital he may have had a small chance of survival, but he was brought to the James Paget Hospital."
The inquest continues on Wednesday.
http://www.bbc.co.uk/news/uk-england-norfolk-32796677