The man called Swedish emergency number 112 at 10pm one evening last summer complaining of pain in his arms and breathing problems, but the nurse who took the call didn't think an ambulance was necessary.
Several hours later, the man called again, telling the operator he felt extremely weak and was still having trouble breathing.
The man was told to lie down and rest.
A third call was placed to SOS Alarm a few hours later by the man's sister, who said her brother had vomited and could barely move.
Finally, 13 hours after the man's first call, an ambulance was sent to the man's home and he was taken to hospital.
He was diagnosed having a heart attack and died less than a day later.
The incident, which took place last year, was reported to the National Board of Health and Welfare (Socialstyrelsen).
Upon reviewing the case, the agency last week issued its findings, criticizing the actions of the nurses who took the initial calls for not focusing on the man's symptoms and failing to interview him correctly.
However, the health board refrained from requiring that SOS Alarm implement any specific changes as the agency is currently conducting a national review of the emergency services operator.
Speaking with the Dagens Nyheter (DN) newspaper, SOS Alarm spokesperson Anders Klarström said the company takes the incident “very seriously”.
“We're doing everything we can to ensure everything goes right and we've added more resources to our patient safety unit in order to work with these sort of quality issues,” he told the paper.