Ambulance delays which may have led to the death of a baby girl from Thetford have been described as a ‘catalogue of catastrophies’ by a cornoner.
On March 11, Bella Hellings was only three months old and had been born with a heart murmur when she stopped breathing.
Her mum Amy Carter urgently dialled 999 and requested an ambulance.
But it took 26 minutes before help arrived.
First, two paramedics couldn’t find the house because the satnav hadn’t been updated.
An ambulance which was thought to be in the area turned out to be queueing outside the Norfolk and Norwich Hospital.
Then a second ambulance was low on fuel and had to spend vital minutes refuelling before it could attend.
Meanwhile another vehicle was only five miles away but the duty manager didn’t realize it could be utilized.
The air ambulance had been despatched but nobody informed the ambulance which was attending the scene and so they left without it.
On the way to the West Suffolk Hospital in Bury St Edmunds the ambulance satnav problems led to further delays.
Coroner William Armstrong described the delays as ‘wholly indefensible’ and concluded that they had ‘reduced the prospects of her survival’.
In a moving conclusion to the inquest, he described Bella as ‘a star that will always shine’, adding: “She will never lose her innocence. She will never grow up, but she will always be loved.”
A statement by Amy Carter and Bella’s father Scott Hellings was read by lawyer Sharon Allison of Ashton KCJ.
She said: “We do not blame any of the individuals involved but we do blame the system.
“We will always believe in our hearts that Bella was let down by the health services when she was at her most vulnerable and when she needed help the most.
“We hope that lessons can be learned from Bella’s death and that other families don’t have to go through the nightmare we continually live with.
“Bella was so special to us in every way possible.
“There will not be a day that passes without our thoughts of what our lives may have been like had she still been here.”
The family are considering taking legal action against the ambulance trust.
A spokeswoman for the East of England Ambulance Service said: “The East of England Ambulance Service (EEAST) instigated a thorough internal investigation following this tragic incident.
“A number of recommendations have been made and actions taken as a result of this investigation.
“The Trust did have two community first responders, one of which was a qualified nurse with training in paediatrics, on scene within 12 minutes.
“They were unable to locate the property for a further 14 minutes, by which time the ambulance crew had arrived.
“The property did not appear on the Trust’s mapping system due to it being a new development and there is often a time lag in such new developments appearing on maps and sat nav system.”
John Martin, Interim Director of Clinical Quality said: “I would like to express my condolences to the family.
“The Trust’s response to Bella was delayed for a number of factors, primarily the difficulty in locating the address due to it being a new build.
“As a result, a number of specific measures have now been put in place and the Trust has raised the problems of the delay in new buildings and developments appearing on mapping systems nationally.