An investigation is being carried out after a woman died in an ambulance while waiting in a queue of around 15 emergency vehicles outside a hospital.
The patient had been outside A&E at Morriston Hospital in Swansea for between 30 and 40 minutes when she died on Wednesday at about 15:40 BST.
The Welsh Ambulance Service and Abertawe Bro Morgannwg health board have launched a joint review.
They said they wanted to have a "full understanding of what happened".
Official figures show less than 70% of patients taken to Morriston Hospital by ambulance are transferred into the care of A&E within the target 15 minutes.
The figures in ABMU's board papers for July show there has been a significant reduction in handovers taking over an hour, but managers note that both Morriston and the Princess of Wales hospital in Bridgend have "struggled to achieve the required level of compliance" with the 15 minute target.
Richard Fitzgibbons from the Association of Professional Ambulance Personnel told the BBC said: "I have never heard of 15 ambulances waiting before, but I quite often hear of up to 10 ambulances waiting outside a hospital."
He added: "While the ambulances are waiting it is having a knock-on effect on other services."
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