A woman died after being turned away by three hospitals, including the Royal Sussex County Hospital, in Brighton, because no beds were available.
But a coroner said that she should have been operated on urgently and in the meantime steps taken to work out where she would be cared for after surgery.
Mary Muldowney, 57, suffered bleeding in the brain – a haemorrhage. She would probably have survived if she had been given immediate life-saving surgery to stem the bleeding, coroner Mary Hassell said.
The coroner, Mary Hassell, set out her concerns in a letter to Brighton and Sussex University Hospitals NHS Trust, which runs the Royal Sussex.
The letter was also sent to two other hospital trust chief executives and NHS England boss Simon Stevens.
The coroner said that Ms Muldowney, from Crawley, was admitted to East Surrey Hospital, in Redhill, at about 10am on Wednesday 20 July last year.
A scan found bleeding in her brain and “transfer to a specialist neurosurgical unit was sought as a matter of urgency”.
The coroner said: “The transfer was refused by St George’s Hospital, the Royal Sussex County Hospital, King’s College Hospital and others on the basis that they did not have an available intensive care bed.
“In desperation, knowing of the neurosurgical expertise of a former colleague, one of the East Surrey Hospital doctors went out of area and rang a consultant neurosurgeon at the Royal London Hospital (RLH).
“Invoking the universal acceptance policy, he accepted transfer immediately though the RLH had no intensive care bed available at that time.
“Meanwhile, at about 1pm, Ms Muldowney woke up very briefly while intubated and interacted with her daughter.”
Despite this, her condition was so serious, the coroner said, that “she needed surgery immediately, regardless of whether there was an intensive care bed currently available at the same hospital”.
She added: “Ms Muldowney was transferred to the RLH and taken straight to theatre at 4.40pm.
“Unfortunately, her pupils had become fixed and dilated in the ambulance during transfer to the RLH and surgery did not save her.
“If she had been transferred promptly, it probably would have.
“During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you.
“The matters of concern are as follows. In the light of the gravity of Ms Muldowney’s situation, with the only definitive treatment being surgery, she required immediate transfer to a specialist neurosurgical unit, yet she was refused transfer by at least three hospitals who said they had no intensive care beds.
“She could have been transferred, undergone surgery, spent time in recovery and then an intensive care bed procured, perhaps even by transferring out a non-neurosurgical patient.
“If such a bed was still unavailable, she could then have been transferred to a different hospital, at least having undergone the time-critical clot evacuation and aneurysm clipping.
“With prompt transfer and surgery, Ms Muldowney would probably have survived.
“In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action.”
Brighton and Sussex University Hospitals said: “We would like to express our deepest sympathies to Ms Muldowney’s family and friends.
“The trust recognises the importance of responding proactively to requests for assistance from other trusts for the benefit of patients, even when, as in this case, it would normally be another tertiary referral centre to whom such a patient would be transferred.
“We often take neurosurgical patients in emergency situations even if we have no beds available, by utilising appropriate areas elsewhere in the hospital as a temporary measure.
“Unfortunately, at the time of referral, Ms Muldowney was not deemed to require life-saving surgery and therefore there was no indication that emergency transfer was appropriate.”