The inquiry is being held at Elgin Sheriff Court

Mr Brown was given detailed directions to the farm, but did not pass on this information - even when the crew called in.

When he was questioned, the ambulance controller was unable to explain why.

Mr Newlands had been badly injured after machinery he was painting toppled onto him at Blackhillock Farm, near Forres.

Two ambulances whose crews knew the area well were available.

But the inquiry was told that a crew from Nairn, some 15 miles away, was despatched instead - and they lost their way.

Accident scene

Sheriff James Penman asked why an ambulance with a local crew had not been asked to attend when it had been available for calls nearly two minutes before Mr Brown passed the emergency to colleagues in Inverness.

The 51-year-old said he could not answer.

The inquiry heard that the crew were simply sent back to their Forres base from Dr Gray's Hospital in Elgin - driving past a lane which could have led them to the accident scene.

Fiscal David Dickson said that an automated log showed Mr Brown had taken a call with detailed directions on how to reach the rural farm.

Back-up ambulance

However, he did not pass them on to the crew - even when they called his Aberdeen control room 10 minutes later.

Mr Brown was unable to explain himself.

He also said it would have been against the rules to send a back-up ambulance and told the court: "I thought they knew where they were going."

It emerged that changes have been introduced to prevent a repeat of the case following an internal inquiry into to the Scottish Ambulance Service's handling of the incident.

The inquiry continues.