A mother who was trapped upside down between sea defence rocks drowned as the tide rose over her after an ambulance controller who received a 999 call initially recorded that she was not near the water, an inquest heard today.
Suffolk Coroner’s Court was told how the apparent misunderstanding about the imminent danger faced by Saffron Cole-Nottage, 32, led to a ‘muddled response’ and helped delay emergency services being sent to help.
While the Coastguard was informed of the incident, the fire service was not contacted by the ambulance service until around 12 minutes into the 999 call.
The delay was said to due to the controller’s computer programme requiring them to ask the caller specific questions which delayed them getting an overview of the incident.
At one stage the controller, who did not realise the tide was threatening to rise over Saffron, even told the caller to tell members of the public to stop trying to pull Saffron out in the misguided belief that her life was not in immediate danger.
The confusion arose during a 999 call about the incident from a girl who spent 19 minutes on the line before an ambulance crew finally arrived at the scene beneath the promenade in Lowestoft, Suffolk.
Tragically, mother-of-six Saffron, who had fallen in a gap between the rocks after slipping while walking her dog with her daughter, drowned before their arrival on the evening of February 2 last year.
The inquest heard how the 999 call was made at 7.52pm by a young friend of one of three people who were trying in vain to pull Saffron free after seeing her legs sticking out of the rocks following her fall on a path at the base of a sea wall.
Saffron Cole-Nottage, 32, drowned after slipping and being trapped between rocks on a Suffolk beach
A transcript of the call which was read to the inquest revealed that the caller had asked for the ambulance service and told the caller that a woman ‘had fallen off the pier and was trapped in between rocks and was unable to get out.’
The hearing was told how it took four minutes to accurately get the location of the incident while the caller stated that ‘the patient was screaming for help’ and the tide was ‘far away’ at the time.
Controller Daniel Joy categorised the call at 7.56pm as being an ‘entrapment’, leading to an ‘entrapment protocol’ being enacted.
At the time, he didn’t record that she needed a specialist rescue and inadvertently selected a different option, although it was still recorded as a most serious Category One call.
East of England Ambulance Service dispatcher Brannon Murrell assigned a crew from Beccles, around a ten mile drive away, to be sent at 7.57pm, and HM Coastguard were informed one minute later
The transcript of the call showed the caller repeating: ‘She fell down head first in the rocks by the seafront.. Two people are pulling her up’.
Mr Joy asked if the woman’s head was in the water, and the caller replied that she was not and her head was jammed in the rocks ‘further at the side’ before she added: ‘This is really serious’.
At one point the phone was passed to Saffron’s daughter who explained that she had warned her mother ‘to stick to the wall because I knew she was going to fall’ because ‘she is drunk’.
The apparent misunderstanding about the imminent danger Saffron faced led to a ‘muddled response’ and helped delay emergency services being sent to help, the inquest was told
The caller repeated: ‘She is not near the side. She is further away. We are trying to pull her up… She is like really screaming and everything… Her whole body is trapped.’
At this stage, Mr Joy urged the caller to tell people at the scene not to ‘attempt to rescue her’, and ‘not to move her’, saying: ‘Stay on the line, I’ll tell you what to do. Wait for the ambulance crew to arrive and tell her not to move’.
But at 7.59pm, the incident was ‘escalated’ as controller Mr Joy re-categorised it as a potential ‘drowning’ incident after the caller reported that Saffron’s head was going under the water, and stated: ‘She is maybe going to drown soon.’
The move led to a rapid response ambulance vehicle which was returned from a call out to Hopton near Great Yarmouth, being sent to the scene as it would get there quicker.
But at 8 minutes and 45 seconds into the call, the caller reported that Saffron was ‘now under the water and has passed out’. They added just over 30 seconds later: ‘She is unresponsive’.
The caller appeared exasperated at the wait for help, saying: ‘How long is it going to be because I think she is going to die?… We don’t know if she is going to drown because her body is fully unresponsive… You can’t see her face.’
Twelve minutes into the call at 8.04pm, the caller said: ‘Can they come quickly as I think she has died’.
The fire service was contacted by the ambulance service at the same time.
The scene of the tragedy. The inquest has heard that Saffron was more than three times the drink-drive limit when she went for a walk with her dog and one of her children
Six minutes later, the caller said she was ‘completely submerged’ before adding at 8.10pm: ‘The ambulance is here. Do you want me to hang up?’
The inquest heard how firefighters eventually arrived on the promenade at 8.22pm, and were at Saffron’s side at 8.26pm, before removing her from the rocks at 8.32pm.
An East Anglian Air Ambulance helicopter which had flown from Norwich landed at the scene at 8.35pm.
Christopher Strutt, a call handler team leader, gave evidence in person at the hearing today and admitted that the fire service should have been contacted by the ambulance service within seconds when it was known that Saffron’s head was trapped.
But he said that controllers had to go through an algorithm, asking questions prompted by their computer and were discouraged from asking unprompted questions until they had gone through their list.
He also admitted there were difficulties as the software had been designed for use in the United States, which has a different emergency response system to the UK’s.
Mr Strutt was asked why the first service was not called when it became clear that Saffron was trapped and in water, and he replied: ‘I do not know.’
Suffolk Area Coroner Darren Stewart OBE suggested that the system was ‘rather clunky’ and had led to ‘a muddled response’. He added that it appeared to have ‘straightjacketed’ the controller into a particular line of questioning and asked: ‘Where’s the common sense?’
The mother-of-six was described as a ‘loving mother who was completely devoted to her children’
Mr Strutt replied: ‘I don’t think it is inaccurate’ before adding that there were ‘a multitude of improvements’ which could have improved the response, such as the caller trying to establish clearly what had happened and more accurate note taking.
He went on to explain how call handlers were ‘obligated to answer key questions’, but a more experienced handler could have moved on ‘at a quicker pace’, and the fire service could have been called earlier ‘with the benefit of hindsight’.
Mr Strutt admitted that it was ‘almost too late to intervene’ by the time the fire service was called.
The inquest heard yesterday how Saffron had 271mgs of alcohol in 100mls of blood at the time of her death which was described as higher than a level ‘normally associated with drunkenness’. The drink drive limit is 80mgs.
Her family described her in a statement as a ‘loving mother who was completely devoted to her children’ and ‘gave just as much love as she received’.
It added that she and her partner Mick Wheeler had a life ‘full of love and laughter’ with their six children. The statement described her children as her ‘greatest joy’ and said her death had ‘left an indescribable void in the lives of her family’.
The statement continued: ‘Saff was truly one of a kind. She was full of life and had the ability to light up any room. Her heart was always open and she would do anything for anyone…
‘To know Saff was never to forget her. She was larger than life, and the life and soul of any party. She left behind, not just cherished memories, but wonderful children.’
The inquest continues.
