An inquest has heard how a mother who became trapped upside down between sea defence rocks drowned as the tide rose, after an ambulance controller who received a 999 call initially recorded that she was not near the water. The apparent misunderstanding about the imminent danger faced by Saffron Cole-Nottage, 32, led to a 'muddled response' and delayed emergency services being sent to help, Suffolk Coroner's Court was told.
Confusion and Delay in 999 Call
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 attributed to the controller's computer programme requiring specific questions to be asked, which delayed an overview of the incident. At one stage, the controller, unaware that the tide was threatening to rise over Saffron, even told the caller to tell members of the public to stop trying to pull her out, in the misguided belief that her life was not in immediate danger.
The Tragic Incident
The confusion arose during a 999 call from a young 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 into 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 to pull Saffron free after seeing her legs sticking out of the rocks. A transcript of the call revealed that the caller asked for the ambulance service and said a woman 'had fallen off the pier and was trapped in between rocks and was unable to get out.'
Call Handling and Categorisation
The hearing was told 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 'entrapment', leading to an 'entrapment protocol' being enacted. At the time, he did not 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 ten miles away, to be sent 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, and the caller replied that she was not and her head was jammed in the rocks 'further at the side', adding: 'This is really serious'.
Escalation and Further Delays
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 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 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'.
However, 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 sent from Hopton near Great Yarmouth, 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', adding just over 30 seconds later: 'She is unresponsive'.
Exasperation and Final Moments
The caller appeared exasperated at the wait, 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' 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, were at Saffron's side at 8.26pm, and removed her from the rocks at 8.32pm. An East Anglian Air Ambulance helicopter landed at the scene at 8.35pm.
Criticism of the Response
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 go through an algorithm prompted by their computer and were discouraged from asking unprompted questions until they had gone through their list. He also admitted difficulties as the software was designed for the US, which has a different emergency response system.
Mr Strutt was asked why the fire service was not called earlier, 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', adding that it appeared to have 'straightjacketed' the controller into a particular line of questioning, asking: 'Where's the common sense?' Mr Strutt replied: 'I don't think it is inaccurate', but added 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.
Alcohol Level and Family Tributes
The inquest heard yesterday that Saffron had 271mgs of alcohol in 100mls of blood at the time of her death, 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'. The statement added that she and her partner Mick Wheeler had a life 'full of love and laughter' with their six children, describing her children as her 'greatest joy' and saying 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.
