Newborn’s death in Oxfordshire prompts coroner’s warning over ambulance response delays
A coroner has raised concerns about delays in emergency call handling and ambulance response times following the death of a three-day-old baby
Last updated 6th Feb 2025
A coroner has warned that delays in emergency call handling and ambulance response times could lead to further deaths, following an inquest into the death of Wyllow-Raine Swinburn.
Wyllow-Raine was born on 27 September 2022 at the John Radcliffe Hospital in Oxford and was discharged the following evening with no significant concerns. In the early hours of 30 September, at her home in Didcot, she became unresponsive while her mother attempted to feed her.
An ambulance was called at 04:38, but the call did not connect to an ambulance service until 04:45. Instructions for CPR were then given and followed. The first paramedic arrived at 05:09, 31 minutes after the initial call. Wyllow-Raine was taken to hospital, where she died later that day.
At an inquest held at Oxfordshire Coroner’s Court on 2 December 2024, Senior Coroner Darren Salter recorded a narrative conclusion, stating that Wyllow-Raine’s cause of death was congenital hyperinsulinism and hypoglycaemia, leading to a cardiac arrest.
Mr Salter has issued a Regulation 28 Report to South Central Ambulance Service (SCAS), highlighting two concerns: the time taken for the 999 call to be connected to an emergency call taker and the length of time for an ambulance to arrive.
“The issue of the delay in being connected to an emergency call taker is more amenable to a systems improvement,” Mr Salter said. He acknowledged pressures on ambulance services but noted that arrangements exist for calls to be transferred to other services with greater capacity.
South Central Ambulance Service have passed on their condolences to Wyllow-Raine’s family, and issued the following statement:
"Losing a child is something that no parent should ever have to experience, and we recognise that waiting so long for their call to be answered and for the ambulance to arrive must have been awful and it is not the service that we aim to deliver. Our internal review identified that there were no missed opportunities to either answer the call or for an ambulance to be dispatched at an earlier time. Our regrettable response time was due to the significant demand that we were experiencing at the time.
"We hope that the evidence provided by both independent experts instructed by HM Coroner that the delays did not cause or contribute to Wyllow-Raine’s death offers her family some comfort.
"Since September 2022, we have undertaken a number of service improvements to increase our ability to respond to patients in a timely manner. This includes increasing the number of emergency call takers we employ, reducing the average call delay from 50 seconds in September 2022 to 10 seconds by September 2024, and introducing new processes in partnership with local hospitals to ensure that ambulance crews are not delayed by more than 45 minutes once they arrive at hospital with a patient so we have more crews available to respond to the most serious emergencies more quickly.
"Whilst this does not change the experience for Wyllow-Raine’s family, we hope that they recognise that we are doing everything that we can to try and ensure that no other family goes through the same experience as they did.”