David Murray died on 29 December 2003 hours after being caught out in cold, wet and windy weather after a night out drinking with friends.
He had an existing serious heart condition and died after suffering a heart attack.
It took the 52-year-old man two hours to get from a friend’s house to his home in Clos St André.
He was wet and cold when he got home and was found by his stepson, having collapsed in the hallway.
The court heard that Mr Murray had set off from a friend’s house at 7 am that day after drinking the previous afternoon and evening.
Around 40 minutes later he was found lying confused in the road at Mont Cochon and complaining of feeling unwell.
The man who found him, Kenneth Wise, who was on his way to work, tried but failed to get Mr Murray into his car to take him home, but he was so concerned for his well-being that he called the police.
At 7.45 am he told the police control room phone operator of Mr Murray’s condition and was assured that officers would be sent.
However, officers were not dispatched until 8.29 am, and they did not arrive in Mont Cochon until 8.39 am.
By the time they arrived, Mr Murray had gone.
The deputy police chief, Lennie Harper, told the hearing that there had been a breakdown in communication between the control room and the officers sent to check on Mr Murray.
The control room operator failed to tell the officers that Mr Murray was feeling unwell, so the call was not given top priority.
Mr Harper explained that a page and a half of notes from the phone call had been condensed into three lines on a fax sent to the operations room, which had not conveyed ‘important elements’ of information.
He added that an internal inquiry had been launched into the system failure and that three officers had been, or were soon to be, reprimanded.
‘The lessons from this have been learned,’ said Mr Harper, adding that a new computer system gave officers responding to calls more information than they previously had under the paper system.
Mr Harper told the hearing that he had received legal advice that there was no link between the response time and Mr Murray’s death.
When Mr Murray got home at 9 am his stepson, Lee Goguelin, called an ambulance.
The paramedics decided not to take him to the General Hospital, telling the adults with him to wrap him up well and give him warm, sweet drinks.
The inquest heard that Mr Murray refused to take the drinks and that a second ambulance was called back at 1 pm, but Mr Murray had already suffered a heart attack and was pronounced dead at the Hospital.
The inquest heard that there had been many aggravating factors which might have led to Mr Murray’s death, but the fact that he had an existing heart condition was probably the most significant.
Neither the family nor paramedics were aware that Mr Murray had had a heart condition.
An expert on hypothermia, Dr Frank Golden, said that the alcohol Mr Murray had consumed could explain why he had not been shivering violently when the paramedics arrived the first time, adding that he could understand why they had not admitted him.
He explained that Mr Murray’s cognitive responses had also been tested and seemed to be relatively good, which also might have masked the seriousness of Mr Murray’s condition.
Dr Golden said that if the patient had drunk the sweet drinks and restored his blood sugar levels, he might well have survived.
Ambulance chief John Moulin said that paramedic training had now been improved and crews now carried thermometers, which could be a useful tool in helping to diagnose hypothermia.
The inquest did not conclude that the paramedics’ actions had led to Mr Murray’s death.