A mum who drowned after getting stuck headfirst in rocks at the seaside might have been saved if the fire service had been alerted more quickly, a coroner has said.
Saffron Cole-Nottage, 32, of Lowestoft, Suffolk, was with her daughter walking their dog at the seafront in the town when she fell on February 2 last year.
A young girl called 999 at 7.52pm, and within the first 30 seconds of the call explained to an ambulance service call handler that the woman was ‘caught head down in the rock’ by the seafront.
The caller made reference to Saffron ‘screaming’ at 7.57pm and 7.58pm before stating a minute later that she was ‘in the water now’.
Suffolk Fire and Rescue Service was the last of the four emergency services to be notified, with the first communication to the fire service at 8.04pm.
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Firefighters were on scene at 8.22pm, and Suffolk area coroner Darren Stewart said it took them ‘less than half a minute’ to free her after initial attempts were made at 8.29pm.
However, she was sadly declared dead at 8.44pm.
The coroner, recording a narrative conclusion, said Saffron ‘died from drowning which has come about due to accidental circumstances’.
He added that the East of England Ambulance Service ‘didn’t immediately contact the fire service’.
He continued: ‘Had the Suffolk Fire and Rescue Service been immediately alerted to the incident … it’s possible that Saffron would have been extricated from the rocks sooner and survived.
‘However, it’s not probable she would have done so.’
The coroner said he would write to the chief executive of the East of England Ambulance Service and the head of NHS England with a series of concerns, including the time taken by the ambulance service to identify the incident was a rescue, during the 999 call, and to pass that information to the fire service.
The coroner said he was also concerned that there was a ‘failure’ to follow guidance from the Joint Royal Colleges Ambulance Liaison Committee that says a submerged person should be treated as a rescue for a minimum of 30 minutes.
He said the clock should start on that 30 minutes when a first responder arrives on scene and confirms that the person is submerged, and described a ‘premature decision to consider Saffron to be deceased’ by the first paramedic in attendance.
The coroner said he would also share his concerns with the National College of Policing as it has national ownership of the Joint Emergency Services Interoperability Principles.
Earlier in Friday’s hearing, Mr Stewart said the 999 call handler had told the caller not to ‘attempt to rescue her and tell her not to move’ Ms Cole-Nottage, after the caller said Saffron was ‘in the water now’.
‘This was an extraordinary message to pass on regarding someone who had just been communicated to be trapped and at risk of drowning,’ he said.
‘This advice appears to have been a result of slavish adherence to the entrapment protocol which was still being followed at this stage (before later moving to a drowning protocol).’
The coroner said that ‘it cannot be said that this instruction had any causative impact on subsequent events’ as members of the public had already been trying in vain to free Saffron.
He praised those who tried to rescue her, and the firefighters who freed her.
He described Saffron, who worked as a cleaner, as a ‘loving mother completely devoted to her children’.
The coroner noted that she ‘had been drinking’ on the day of the accident.
The inquest was earlier told that a level of 271 milligrammes of alcohol per 100ml of blood was recorded for Ms Cole-Nottage.
The legal limit for driving in England is 80 milligrammes of alcohol per 100 millilitres of blood.
Saffron’s partner said: ‘Saff was truly one of a kind, bubbly, fun, and full of life. She had the rare ability to light up any room, lifting the spirits of those around her.
‘It has been a long and difficult 15 months to get here. We have finally got some closure and an understanding of what actually happened to Saff that night.
‘Hopefully the emergency services have listened to the coroner and going forward no other family has to go through what we went through.’
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