The A&E department was busy the night Mr Thomas went

David Morgan, 54, from Trethomas near Caerphilly, injured his head after falling down stairs in his home.

He tried to treat his injury and two days later went to the Royal Gwent Hospital in Newport, but left without any treatment after a five-hour wait.

He died the same night. An accidental death verdict was recorded.

The inquest in Newport heard how, after falling down the stairs at home in September 2004, Mr Morgan used tea towels to staunch the flow of blood. Two days later, after suffering bad headaches, he called his social worker.

In an ideal world Mr Morgan would have been seen immediately but we do not live in an ideal world Coroner David Bowen

Mr Morgan, who the inquest heard suffered from a depressive illness and had a problem with alcohol, was taken to the Royal Gwent Hospital where he waited alone for nearly five hours to see a doctor.

However, the inquest heard he chose to leave the hospital without being treated.

Hospital records showed that he was called to be seen at 2300 GMT, three-quarters of an hour after he had arrived home, where his cousin was waiting for him.

She could not persuade Mr Morgan to go back to the hospital and the inquest heard police found him dead the next day.

The inquest was told on arrival at hospital Mr Morgan was assessed and placed on the lowest priority category where a target waiting time of 120 minutes was usual.

But the department was busy that night and Mr Morgan was not treated within that time.

'Limited resources'

Gwent coroner David Bowen said Mr Morgan died from an untreated blood clot on his brain that developed when he banged his head.

But he added that the delay in treatment had not contributed to Mr Morgan's death. Had he waited in the hospital he would have been seen and received treatment to save his life, he said.

Mr Bowen said Mr Morgan had "deprived himself of treatment" but said that this was because "unfortunately not only was he not accompanied but he was not one to make a fuss.

"It seems likely that he may not have given a full account of the severity of his headache."

"In an ideal world Mr Morgan would have been seen immediately but we do not live in an ideal world.

"We live in the real world with an NHS with limited resources which have to prioritise patients."

The coroner said patients should be accompanied if at all possible and recommended that the hospital triage system is adapted so that patients are observed during the waiting time and reassessed if that is extended.