A coroner has spoken of his "astonishment" that a paramedic was told not enter to a Derby pub where a collapsed woman later died.
Derby coroner Robert Hunter said he also had "grave concerns" that a crew close to the pub was not dispatched because it was on a meal break.
Melissa Procter-Blain, 32, died of a blood clot in Spondon in July 2009.
But he said the woman's accidental death would not have been prevented if an ambulance had arrived earlier.
Dr Hunter said he would write to both East Midlands Ambulance Service and the minister of state for health about meal breaks and response times.
Dr Hunter said: "I am astonished beyond belief that an emergency service can despatch a highly-skilled and experienced paramedic to a life-threatening emergency with blue lights and sirens, only to tell that person not to enter and wait for back-up.
"Paramedics are the frontline staff dealing with life-threatening medical emergencies and injuries. Their job does not overstate the fact that every second counts.
"Their job is not working in a factory, nor filling out forms in an office where time is not of the essence. It is literally a matter of life and death."
Dr Hunter said there was a delay of about four minutes involving emergency staff arriving at the Crown Inn because a single responder paramedic was sent instead of a full crew that was on a meal break nearby.
John Page, Mrs Procter-Blain's stepfather, said: "When it is a life threatening situation, surely to God they must respond to that - what they are actually saying is that someone's life is not worth the price of a cup of tea, somewhere along the line there is something sadly wrong."
Earlier the inquest was told the paramedic, who cannot be named for legal reasons, had refused to enter pub due to an intimidating atmosphere inside.
But the paramedic disputed this, saying she had been told not to go inside by the control room, but decided to go in anyway.
The coroner said Mrs Procter-Blain's death was caused by a blood clot that had followed an earlier accident at the pub in May 2009 when she fell and dislocated her knee.
This accident led to deep-vein thrombosis which in turn caused the blood clot in her lungs, he said.
He said both the ambulance service and unions need to reconsider the policy on meal breaks to allow "the most appropriate vehicle" to respond.
An ambulance was not called to help the dying woman because the crew still had two minutes of a meal break left, the inquest was told.
The ambulance policy is to send a vehicle on a break only for a major incident - but not a life-threatening one, the inquest heard.
East Midlands Ambulance Service (EMAS) confirmed there was an ambulance a short distance away but its crew had not finished its 45-minute break and could not be called despite Ms Procter-Blain's critical condition.
After the inquest, an EMAS spokesman said: "The solo paramedic was greeted with a hostile and intimidating atmosphere.
"The solo paramedic and backup crew provided all possible appropriate treatment but sadly despite their efforts to treat Melissa, her medical condition was such that death was inevitable."