A CORONER will be writing to South Central Ambulance Service after she found that a delayed ambulance may have contributed to the death of an 18-year-old.

Student Ella Chatfield, of Fettiplace Road in Witney, died on February 23 this year from septicemia after suffering from tonsillitis two weeks prior.

The 18-year-old had been experiencing severe abdominal pain, fainting spells, and vomiting the morning of her death leading to her mother calling 999 at 5.15am.

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An ambulance was dispatched but was quickly told to stand down as Ella's condition was changed from a ‘category one’ emergency, meaning ‘a life-threatening condition’, to 'category two, a serious condition'. 

However, the coroner stated the condition change should not have been made as Ella was seizing and unable to breathe at the time.

The ambulance was dispatched again 10 minutes later as Ella’s condition worsened. Paramedics attempted resuscitation but Ella was later pronounced dead at 6.52am.

Assistant coroner Joanna Coleman told an inquest yesterday (October 4) that the ambulance ‘should not have been told to stand down’ and she considers that the delay in the service ‘may have contributed’ to Ella’s death.

The inquest in the early hours of February 23, Ella’s mum called 111 after her daughter was frequently passing out and experiencing severe pain at 3.17am.

She was told a clinician would call her back but Ella’s symptoms worsened so she called the emergency telephone line twice more.

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At 5.15am, she phoned 999 after Ella had collapsed on the landing.

“I felt like I wasn’t being listened to,” she told the inquest. “Her body started juddering so I called 999 who said she might having a seizure.

“I started CPR and felt the call taker wasn’t giving me any support and there was a long time in silence.

“At one point they asked me to get a nearby defibrillator but couldn’t tell me the code to access it.

“The pain and trauma this has caused is unbelievable – I watched my daughter deteriorate and no one was taking me seriously.

“I can’t believe an ambulance was told to stand down when she wasn’t breathing – she was a young girl and she never should have passed away.”

She added that 999 call taker had also tried to ‘hang up’ stating they were ‘really busy’.

Paramedic Paul Davies, of SCAS, audited the emergency calls following complaints from Ella’s family and believed that three of four of the call takers had been non-compliant. 

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Ms Coleman provided a narrative conclusion to the inquest stating she would write to SCAS to express her concerns about the ambulance being told to stand down.


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This story was written by Gee Harland. She joined the team in 2022 as a senior multimedia reporter.

Gee covers Wallingford, Wantage and Didcot.

Get in touch with her by emailing: Gee.harland@newsquest.co.uk

Follow her on Twitter @Geeharland

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