The grieving family of a woman in her 70s who died while said to be waiting in a queue of 15 ambulances outside Morriston Hospital, Swansea, believe the system let her down.
Sonia Powell, who had a suspected heart attack, had to wait "at least an hour".
The ambulance service and local health board had said the wait was between 30 and 40 minutes.
Mrs Powell's granddaughter said a doctor came only "five minutes" before she died.
Kim Thompson spoke out as an investigation into what happened before her grandmother died in the ambulance outside the hospital on Wednesday afternoon was launched.
She said her grandmother, from Banwen in the Neath Valley, was at Neath Port Talbot Hospital originally, but was being transferred to Morriston Hospital having had a suspected heart attack and fluid on the lungs.
The family was told Mrs Powell, who had been in hospital since the start of the week, would be transferred to the cardiac unit at Morriston Hospital.
'Lack of communication'But Ms Thompson said on arrival the ambulance driver took in Mrs Powell's notes to the hospital where they were examined by a doctor who expressed frustration that a decision had been made to transfer her there.
At the time Ms Thompson said eight to nine ambulances were queuing there because there were no free beds.
She said the family were concerned about how her grandmother "was dealt with at the end" and were particularly concerned about what they believed to be "the lack of communication between the hospitals".
However, she paid tribute to the compassion of individual staff.
In particular, Ms Thompson said "you couldn't fault" the ambulance worker, and the hospital chaplain at Moriston "couldn't have done more for us" in the aftermath.
'Knock-on affect'Both the Welsh Ambulance Service and Abertawe Bro Morgannwg health board said they wanted to have a "full understanding of what happened".
Official figures show less than 70% of patients taken to Morriston Hospital by ambulance are transferred into the care of A&E within the target 15 minutes.
The figures in ABMU's board papers for July show there has been a significant reduction in handovers taking over an hour, but managers note that both Morriston and the Princess of Wales hospital in Bridgend have "struggled to achieve the required level of compliance" with the 15 minute target.
Richard Fitzgibbons from the Association of Professional Ambulance Personnel told the BBC said: "I have never heard of 15 ambulances waiting before, but I quite often hear of up to 10 ambulances waiting outside a hospital."
He added: "While the ambulances are waiting it is having a knock-on affect on other services."
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