Mother and daughter found dead months after 999 call ‘missed opportunity'

Independent

2 days ago

A 999 call made by a mother who was later found dead along with her 'entirely dependent' daughter led to no ambulance being sent despite the call handler being given their address and postcode, an inquest has heard.
Nottingham Coroner's Court was told Alphonsine Djiako Leuga, 47, suffered from sickle cell anaemia and died from pneumonia, while her 18-year-old daughter Loraine Choulla had learning difficulties and Down's syndrome and relied on her mother for food and hydration.
A inquest into the deaths, expected to last for five days, began on Monday with assistant coroner Amanda Bewley hearing that Ms Leuga called 999 three months before her body was found, telling a call hander she was cold and could not move.
The hearing was told that during the call, made shortly after 1pm on February 2 last year, Ms Leuga groaned, requested an ambulance and said 'I need help to my daughter' and 'I'm in the bed, I feel cold and can't move' before cutting off the line.
She also gave details of her address in Hartley Road, Radford, Nottingham, where her body and that of her daughter were found on May 21 last year.
Giving evidence to the inquest, East Midlands Ambulance Service's head of patient safety, Susan Jevons said the call handler, an emergency medical adviser, should have referred the call to the control room despatch officers.
Ms Jevons said attempts had been made to call Ms Leuga back, but she told the inquest: 'The call should have been left for an ambulance to attend once we had got the address, which we had.
'The ambulance didn't go to the address because the emergency medical adviser, thinking it was an abandoned call, closed the call down.
'So it wasn't visible to anybody within the emergency operations centre.'
The coroner told Ms Jevons she would have to consider the possibility that sending an ambulance to the address 'might have been the difference between life or death' for Loraine.
The inquest was told that Ms Leuga was admitted to hospital for a blood transfusion in late January last year as she was critically ill with very low iron levels, and was given a 'pragmatic' discharge linked to her daughter's care needs.
The coroner asked Ms Jevons whether, if she found at the end of the inquest that Loraine had died after her mother, there had been a 'missed opportunity' in relation to the teenager's death.
Ms Jevons responded: 'Yes, there was a missed opportunity for an ambulance to attend Alphonsine when she requested one.'
Earlier, pathologist Dr Stuart Hamilton told the hearing by video-link that the mother and daughter were both likely to have been dead for 'weeks to months' before they were found, rather than for days or hours.
Dr Hamilton said his initial cause of death following a post-mortem examination on Ms Leuga was pneumonia of uncertain cause, while her daughter's cause of death could not be established.
Answering questions from the coroner, the pathologist said he could not rule out that Ms Leuga had died on the day of the 999 call.
The body of Loraine, who the inquest was told was 'entirely dependent on her mother to meet her hydration and nutritional needs', showed no evidence of any third party involvement.
Dr Hamilton said of the teenager: 'Unfortunately, based on the post-mortem examination and additional tests alone, it is my view that the cause of death is classed as unascertained – that is, I am not able to give a cause of death on the balance of probabilities.'
Asked to comment on the possibility that Loraine's death may have been because of dehydration or malnutrition, Dr Hamilton answered: 'There is nothing in my findings that say any of that is incorrect.'
Loraine was more likely to have died from dehydration than malnutrition, the witness said, if it was accepted that she 'wasn't able to make the decision to drink water' because of her difficulties.
The inquest continues.