Worcestershire Coroner Gearint Williams concluded the error could not be conclusively pinpointed as the cause of Mr Nishigaki's death.
His family are now taking legal action to kick-start "systemic change" within the NHS and ensure ambulances are stationed closer together in rural areas.
Mr Nishigaki's daughter-in-law Emma Nishigaki, 51, said: "We are currently at the stage of writing a letter of intent to West Midlands Ambulance Service."Our main motivation is that we want the organisation responsible to be down on record as accountable."If things like this don't happen there is no incentive to change policy. "They have changed policy when it comes to having an ambulance based in Evesham but that is only because they have been shamed into.
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