Three-day-old baby’s death not caused by ambulance delay, inquest hears
The court heard how the family waited more than 30 minutes for an ambulance to arrive
Last updated 3rd Dec 2024
A baby that lived for only three days did not die because of an “awful” wait for an ambulance to arrive, an inquest has heard.
Wyllow-Raine Swinburn was born by a caesarean section on 27 September 2022, at 10lbs 5oz and appearing to be healthy.
However, only three days later on the 30 September 2022, the newborn died at the John Radcliffe Hospital.
Oxford Coroners Court heard how the family from Didcot gave the young baby CPR as they waited more than half an hour for an ambulance to arrive.
In an earlier hearing, the court heard that an ambulance was supposed to arrive within seven minutes in around 90% of cases, according to South Central Ambulance Service.
Karen Sillicorn-Aston, Clinical Governance Lead for South Central Ambulance Service (SCAS) described the families experience as “awful” and said: “Anything over 30 minutes we would consider a long wait.”
The court heard how the 999 call was disconnected by a BT operator, whose job it is to listen in to all calls before they’re answered, which led to nearly an eight-minute delay in the phone call.
The coroner said he would be writing to both SCAS and BT asking them to review waiting times and call-handling procedures.
In a statement from the Oxford University Hospitals Trust, Professor Andrew Brent, Chief Medical Officer, said: “On behalf of the Trust, I would like to offer my deepest sympathies to Wyllow-Raine’s family.
"We have carefully considered what could be learned from this tragic case and, although we have not identified anything that could have prevented Wyllow-Raine’s death, we have identified some areas for learning which will enable us to improve further the care we deliver to babies in the future.”
"It has felt like a nightmare I can’t wake up from"
Professor Simon Mitchell, an independent expert in neonatal cases, was asked whether the ambulance arriving sooner would have saved Wyllow-Raine, he replied “on the balance of probability, no”.
Prof Mitchell told the court, from his experience he feels the immediate cause of death to be cardiac respiratory arrest, “due to congenital hyperinsulinism and hypoglycaemia”, which he says is “a relatively rare condition”.
The coroner accepted this to be the recorded cause of death.
In a statement from the family, Ms Pill said: “Even though Wyllow-Raine was only here for a small moment in time, she will always mean the world to me.
“It is hard to put into words how difficult it has been losing Wyllow-Raine. It has felt like a nightmare I can’t wake up from.
“I will never get to see her grow up, get to know her personality, or see what she would have achieved. She will never get the opportunity to find the things she loves, and my daughter now has to grow up without her big sister.
“Wyllow-Raine will still never leave my thoughts.”
In a statement a spokesperson from South Central Ambulance Service said:
“On behalf of South Central Ambulance Service we offer our sincere condolences to Wyllow-Raine’s family. 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.”