An inquest has heard that a mother who became trapped upside down between sea defence rocks drowned as the tide rose over her, following a misunderstanding by an ambulance controller who initially recorded that she was not near the water.
Incident Details
Suffolk Coroner's Court was told that the apparent confusion about the imminent danger faced by 32-year-old Saffron Cole-Nottage led to a 'muddled response' and delayed emergency services being sent to help. While the Coastguard was informed, the fire service was not contacted by the ambulance service until approximately 12 minutes into the 999 call.
The delay was attributed to the controller's computer programme requiring specific questions to be asked, which prevented a swift overview of the incident. At one stage, the controller, unaware that the tide was threatening to rise over Saffron, even instructed the caller to tell bystanders to stop trying to pull her out, mistakenly believing her life was not in immediate danger.
The 999 Call
The confusion arose during a 999 call from a young girl who spent 19 minutes on the line before an ambulance crew arrived at the scene beneath the promenade in Lowestoft, Suffolk. Tragically, mother-of-six Saffron, who had fallen into a gap between rocks after slipping while walking her dog with her daughter, drowned before their arrival on the evening of February 2 last year.
A transcript of the call, read to the inquest, revealed that the caller asked for the ambulance service and reported that a woman 'had fallen off the pier and was trapped in between rocks and was unable to get out.' It took four minutes to accurately identify the location, and 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 an 'entrapment,' initiating an 'entrapment protocol.' However, he did not record that a specialist rescue was needed and inadvertently selected a different option, though it was still recorded as a Category One call.
Response and Delays
East of England Ambulance Service dispatcher Brannon Murrell assigned a crew from Beccles, about ten miles away, at 7.57pm, and HM Coastguard were informed one minute later. The transcript 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; the caller replied it was not, but her head was jammed in the rocks 'further at the side,' adding, 'This is really serious.' At one point, Saffron's daughter explained she had warned her mother 'to stick to the wall because I knew she was going to fall' because 'she is drunk.'
The caller continued: '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.' Mr Joy urged the caller to tell people 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.'
At 7.59pm, the incident was 'escalated' as Mr Joy re-categorised it as a potential 'drowning' after the caller reported that Saffron's head was going under the water, stating, 'She is maybe going to drown soon.' This led to a rapid response ambulance vehicle being redirected from Hopton near Great Yarmouth to the scene.
At 8 minutes and 45 seconds into the call, the caller reported that Saffron was 'now under the water and has passed out,' and just over 30 seconds later added, 'She is unresponsive.' The caller expressed exasperation, 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. Six minutes later, the caller said she was 'completely submerged,' and at 8.10pm added, 'The ambulance is here. Do you want me to hang up?'
Arrival at Scene
Firefighters arrived on the promenade at 8.22pm, were at Saffron's side at 8.26pm, and removed her from the rocks at 8.32pm. An East Anglian Air Ambulance helicopter from Norwich landed at 8.35pm.
Christopher Strutt, a call handler team leader, gave evidence and admitted that the fire service should have been contacted within seconds when it was known that Saffron's head was trapped. However, he said controllers had to follow an algorithm, asking questions prompted by their computer, and were discouraged from asking unprompted questions until the list was completed. He also acknowledged difficulties as the software was designed for the US emergency response system, which differs from the UK's.
Mr Strutt was asked why the fire service was not called when it became clear Saffron was trapped in water, and he replied, 'I do not know.' Suffolk Area Coroner Darren Stewart OBE suggested the system was 'rather clunky' and led to 'a muddled response,' adding that it appeared to have 'straightjacketed' the controller and asked, 'Where's the common sense?'
Mr Strutt replied, 'I don't think it is inaccurate,' but noted there were 'a multitude of improvements' that could have been made, such as establishing clearly what happened and more accurate note-taking. He explained that call handlers were 'obligated to answer key questions,' but a more experienced handler could have moved on 'at a quicker pace,' and with hindsight, the fire service could have been called earlier. He admitted it was 'almost too late to intervene' by the time the fire service was called.
Toxicology and Family Tribute
The inquest heard that Saffron had 271mg of alcohol per 100ml of blood at the time of her death, more than three times the drink-drive limit of 80mg. Her family described her as a 'loving mother who was completely devoted to her children' and 'gave just as much love as she received.' They stated that she and her partner Mick Wheeler had a life 'full of love and laughter' with their six children. Her children were her 'greatest joy,' and 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.
