A football fan who suffered a cardiac arrest at a match and received care described by witnesses as a "shambles" died due to natural causes, an inquest has found.
Mark Townsend, 57, from Birmingham, collapsed at Hillsborough Stadium while watching West Brom play Sheffield Wednesday on 28 September last year.
Senior coroner Tanyka Rawden said a prevention of future deaths report would consider the location of staff with radios, as stewards had struggled to find one who could then summon paramedics.
The subsequent one-minute, three-second delay was "unnecessary" but did not cause or contribute to his death, Ms Rawden told Sheffield Medico-Legal Centre.
"Stewards have to be clear all the time where radios are, and I do not feel they were on this occasion," she said.
"Every second counts in an emergency situation, and where changes can be made in the hope lives can be saved in the future, then they should be made."
Ms Rawden found the medical cause of death to be a myocardial infarction - or heart attack - caused by coronary artery disease, contributed to by high cholesterol.
CCTV showed a supporter, who had been sitting near Mr Townsend in the Leppings Lane stand, speaking to a steward just before 13:00 BST after he collapsed.
Chelsea Jones, a West Brom fan and off-duty paramedic, quickly started CPR, which Ms Rawden said had given him "the best possible chance" of survival.
Dr Richard Stones, a fellow West Brom supporter in the away end who had tried to help Mr Townsend, previously described the care given at the ground as a "shambles".
"The stewards were just looking at me. There was no communication," he said.
Paramedics from Lambda Medical, a private ambulance service which provides crowd care at the ground, arrived about four minutes after being notified and provided defibrillator shocks.
No ventilation was provided, however, until 15 minutes later which Ms Rawden said was "likely to have contributed to but not directly caused" Mr Townsend's death.
At 13:14, about a minute after being moved to the concourse on a stretcher, Yorkshire Ambulance Service (YAS) paramedics arrived, having been called by their commander at the ground.
Standard procedure for a cardiac arrest sees a number of paramedics surround the patient, each with different roles and overseen by one team leader.
Lewis Wright, director of Lambda Medical, previously told the inquest that he had been the team leader until that point.
But critical care paramedic Sam Hewson, who took over as leader, said: "I have asked for an initial handover and not received one; I am looking for someone who had taken lead and can't find anyone... there was no leadership in place."
Ms Rawden said there had been "confusion" between the two teams, both of which had an access point for providing drugs to Mr Townsend.
"It cannot be said whether this confusion caused or contributed to his death," she said.
The inquest heard previously that Mr Townsend had had a "very poorly heart" and suffered a "massive" heart attack in hospital.
Ms Rawden said it had been "on the balance of probabilities, unsurvivable".
She said all her preliminary concerns about the event had been acted on since the incident, other than staff access to radios, which would be dealt with in the report.
Improvements included joint training with YAS and Lambda Medical, more frequent practice extrications and clearer markings of rank and role on Lambda paramedics' uniforms.
She told Mr Townsend's family, who had attended the inquest every day: "I am sorry about what happened, and I cannot undo the devastation it has caused."
“I know from what you have said that he will always and forever be in your hearts.”
She said a statement from Mr Townsend's wife, Marion, shared earlier would "stay with me for a long time".
Mrs Townsend said she had been "so lucky to experience a true all-encompassing love with Mark".
"Many people do not get that in their lifetime, and I am truly grateful," she said.
Steve Townsend, Mark's brother, described him as one of the "nicest people you would ever meet".
"If it was his last pound in his pocket and you needed it, he would give it to you," he said.
Sheffield Wednesday FC said in a statement after the inquest: "Whilst the coroner's findings have confirmed that the medical response time on the day was comparable to what might be expected in a hospital setting, we will be carefully considering the coroner's recommendation to explore whether there may be ways to further improve the speed of communication on match days as part of the club's ongoing commitment to maintaining the highest standards of safety at Hillsborough stadium."