An Adelaide man who died on the side of the road while waiting for an ambulance may have survived if help had arrived in time, an investigation has found.
The inquiry into the man's death last month was launched amid ongoing problems with ambulance response times across the city.
The 47-year-old had been driving but pulled over and called triple zero when he experienced jaw and chest pains.
An ambulance took 41 minutes to arrive and by that time the man could not be revived.
In a report released on Tuesday, SA Chief Health Officer Michael Cusack found the ambulance service had reduced capacity to respond to urgent calls on the day in question.
But he said the urgency of the man's condition was not fully appreciated at the time of his initial call.
"Had a paramedic crew been with (the man) at the time of his cardiac arrest he may have been successfully resuscitated at the scene or en route to an emergency department," Dr Cusack said.
"The information that (the man) provided in his triple zero call indicated that he was at high risk as he described typical symptoms of chest pain radiating to his jaw, with a background history of a previous heart attack.
"Additionally, he was alone without someone available nearby to monitor his condition."
South Australian Health Minister Chris Picton said the man's death was a tragedy.
"This report clearly sets out the issues that led to the tragedy and how we can take action to prevent similar tragedies from occurring," Mr Picton said.
"This is a call to action for every part of the health system to improve to address these key safety issues."
The Ambulance Employees Association said that at the time of the man's death there were 20 uncovered life-threatening emergencies across Adelaide, with ambulances ramped at all major hospitals, some for more than six hours.
"This patient was only minutes away from hospital. Ramping deprived this patient of his best chance of survival," the association said.
Dr Cusack also handed down findings on Tuesday into the delays in an ambulance responding to a cancer patient who fell while pruning trees at her home, fracturing her hip.
Despite multiple calls to the ambulance service, the 77-year-old woman waited for more than two and a half hours for help, prompting a finding that her care was "far below what would be expected".
"Not only did this result in unnecessary pain, but risked further harm as the extent of her injuries were at that stage unknown," Dr Cusack said.
Among a series of recommendations, he called for changes to ensure patients identified as having a heart attack received the first available ambulance.