A coroner has criticised ambulance services after paramedics abandoned treating a man who had attempted suicide.
Ashley Walker, 25, had taken a toxic liquid at his home last summer and then called 999.
Paramedics rushed to the property in Kenilworth, Warwickshire, and started to treat him with oxygen.
He was responding well to treatment when a senior manager called on the crew to leave.
The manager thought the substance had been spilled not swallowed and was therefore toxic to those treating him.
Mr Walker was left for some 45 minutes until the fire service arrived and declared the scene safe.
When the paramedics returned Mr Walker had no pulse and despite CPR he was later pronounced dead.
Warwickshire Coroner, Sean McGovern, said there had been 'a real chance' that Mr Walker could have been saved.
An antidote exists that can reverse the damage if taken within a couple of hours.
Although the substance was a common cause of poisoning the antidote is not routinely carried on ambulances.
In a prevention of future deaths letter, the coroner criticised West Midlands Ambulance Service for calling off the paramedics and for a failure to carry the antidote.
Mr Walker had previously taken overdoses and expressed suicidal thoughts to mental health specialists.
But an assessment ruled he did not suffer from acute mental issues and at the time expressed no suicidal intent.
A West Midlands Ambulance Service spokesman said: "We have received a Prevention of Future Deaths Report from the Warwickshire Coroner in relation to the inquest into the death of Ashley Walker.
"The Trust declared the case as a 'Serious Incident' at the time and carried out a full investigation to look at lessons that could be learnt. We will be replying to the coroner."
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