A mountain biker who died after crashing into a tree while riding along a trail he built waited more than an hour for an ambulance to arrive.
Ryan Bullimore was riding along a trail Tirpentwys in woods near Pontypool when he crashed into a tree on June 5, 2018.
The 23-year-old suffered major injuries and was taken to the Royal Gwent Hospital in Newport where he died later than evening.
Mr Bullimore built the Tirpentwys mountain bike trail with friends and it has since become a popular location for athletes in the sport.
An inquest into his death at Gwent Coroners' Court on Thursday heard ambulances did not arrive at the scene of the accident until an hour after the initial 999 call was made.
Assistant coroner for Gwent Sarah Le Fevre summarised a statement given by Mr Bullimore's father Jason Bullimore.
Mr Bullimore told the court his son was a keen climber and mountain biker who was considered a hard worker by many of his employers.
"As many people know Ryan's hobbies didn't include many other things than downhill cycling and climbing," he said.
"He spent a lot of his time effectively living in the woods at Tirpentwys where he invested all his time into creating a mini-Whistler of his own."
Jason Bullimore said his son had discovered the location for his Tirpentwys bike trail on his 21st birthday and it has since become celebrated track among those interested in the sport and is accessible to many young people in the area.
On the day pf the crash Jason Bullimore said he arrived at the hillside at about 10.32pm to find his son being carried on a stretcher by friends and paramedics.
He said he called out "What have you done now?" as he was not aware how serious the situation was and was met with "silence".
“At that time we were about seven minutes away from the ambulance and I already knew Ryan’s chances of surviving were zero. The damage to his brain was too great.”
Ryan Bullimore, from Griffithstown, Pontypool, was taken to the Royal Gwent Hospital where he was pronounced dead at 11.42pm.
PC David Thomas, of Gwent Police's collision investigation team, inspected the scene in the days following the incident. He said Mr Bullimore had collided with a large tree in the middle of a compacted mound of dirt known as a “berm”.
PC Thomas said Mr Bullimore’s friend heard a loud "bang” before finding him unconscious with blood coming from his head and face and called an ambulance.
PC Thomas said the helmet Mr Bullimore was taken away for examination but no safety faults were found and the bike he was riding was in perfect condition.
Kate Blackmore, area manager for the Welsh Ambulance Service Trust (WAST), said the initial call to emergency services occurred at 8.47pm and lasted about one hour.
The first ambulance crews did not arrive at the car park near the trail until 9.46pm and crews were unable to reach Mr Bullimore until about 10.02pm due to the trail's location a distance from the car park.
Ms Blackmore explained that call handlers ask set questions within 34 protocols to assess the prioritisation of calls. She said the incident was given an "amber two" prioritisation until 9.24pm when it was upgraded to red – the most urgent classification which requires a response within eight minutes.
"It would have been more appropriate to select a trauma protocol so protocol 30 which would have been a traumatic incident," she said.
Ms Le Fevre recorded a medical cause of death of cerebral contusions, subarachnoid haemorrhage, and blunt trauma.
"Ms Blackmore tells me very frankly through her evidence that her audits suggest to her that the call handler on the evening may have selected the incorrect protocol," she said.
"Had it been her taking this call then it might have been it could have been protocol 30 that would have been selected rather than protocol 12.
"However it is likely, I think strongly likely, that the highest prioritisation that would have been accorded to this particular call before 9.21pm on June 5 would have been an amber one band.
"[Amber one] had no particular response time or target allocated to it and as I have also heard from Ms Blackmore, WAST was operating under significant and recognised demand on its system and resources."
The coroner concluded that Mr Bullimore died as a result of an accident.
Speaking after the hearing, Jason Bullimore said: "I think the coroner did a really good job. He should have been on a red (ambulance prioritisation) before 9pm."
Mr Bullimore's partner Ceri Edmunds said: "We just love and miss him to be honest. It's been a tough time."
