A paramedic missed an opportunity to deliver vital care that could have saved a Bristol meningitis victim's life, a coroner has said.
Mthuthuzeli Mpongwana waited for almost six hours for an ambulance but was initially told by a paramedic he had "man flu". He died two days later.
Senior coroner for Avon, Maria Voisin, ruled there were "failings" in his care and reached a narrative conclusion.
The ambulance trust has apologised for the "unacceptable delays" in his case.
Ms Voisin said: "Mr Mpongwana died from natural causes contributed to by a failure to take appropriate action in the face of an obvious need.
"That failure was at 1:50am on January 6, when a P1 (high priority ambulance) back-up should have been requested and benzylpenicillin should have been administered.
"The inappropriate care that was given resulted in a missed opportunity for medical treatment to be given."
Mr Mpongwana's wife, Lisa Armitage, called the 111 NHS non-emergency number at 22:30 GMT on 5 January, reporting her husband was suffering from a sore neck, struggled to look at light and had a bad headache.
She was advised to wait outside her home and that a rapid response vehicle with blue lights on would attend. She was also warned her husband could have meningitis.
Avon Coroners Court heard that paramedic Dana Noriega failed to spot signs of both sepsis and meningitis and dismissed his symptoms as "man flu".
The court also heard that Mr Mpongwana, told the paramedic he had HIV and had been treated for tuberculosis [TB].
Mr Noriega failed to administer penicillin which should have been given as soon as possible, as he was worried it would react with the patient's other medication.
Points West's health correspondent, Matthew Hill:
This case highlights the extreme pressure that lone paramedics can face - in this case a paramedic who admitted feeling exhausted at the start of his shift having worked over the new year.
Mr Noriega was dealing not only with a suspected meningitis sufferer but also with a man who had just told him he had HIV as well as treatment for TB.
He thought Mr Mpongwana was improving and didn't give antibiotics immediately because he was concerned they might react badly with other medication he was on.
The paramedic also admitted he should have called for a 15-minute emergency response ambulance straight away but he knew all blue-light ambulances were tied up.
So he tried to circumvent system by calling for a 40 minute response ambulance, which from his experience could work out quicker, but nothing came.
Over the past 20 years there has been a trend to increasingly employ single-handed practitioners.
The idea is that you have more units out in the field to react when they are needed.
The downside is that they often cannot transport patients to hospital - which is why the trust is now trying to address that.
Other delays were made by downgrading the case and failing to call for a high-priority ambulance until 03:50, by which time Mr Mpongwana's condition had deteriorated.
He suffered a brain injury and died in hospital the following day.
A spokesman for South Western Ambulance Trust said it was "very sorry for the unacceptable delays Mr Mpongwana suffered" and had explained its findings to his wife Lisa.
He added that "a number of improvements have been identified, especially around requests for back-up from clinicians on scene with patients who need to be transported to hospital".
Mr Noriega's case has been referred to the Health Care Professions Council and he has since left the trust.
The trust was told by the coroner that no further action was needed.