A failure to record the seriousness of a 999 call meant it took two hours for an ambulance to reach a woman who died by the time paramedics arrived.
Norfolk Coroner's Court heard today (Monday) how Jeanette Charity, 47, died on January 26 this year at her sister's home in Ivy Green, Gorleston, where she had been living since 2013.
She had called emergency services at 3.11am complaining of abdominal pain and breathing problems. But instead of recording the call under the more serious symptom of breathing problems, the East of England Ambulance Trust (EEAST) call handler instead picked up on the abdominal pains.
Giving evidence to assistant coroner Johanna Thompson, Hugo Brice, at the time a serious incident investigator at EEAST, said if the call had been coded correctly, the target to reach Ms Charity would have been eight minutes.
Instead the record was caught in a loop of being added to a queue for a call or for an ambulance for more than an hour. Eventually, when a medical professional attempted to call her and got no answer, an ambulance was dispatched at 5.16am. When they arrived - within minutes - they found Ms Charity dead.
Mr Brice said breathing difficulties was one of four symptoms which prompted the most urgent response. He said: 'It's the golden rule, it's day one stuff.'
Chris Hewetson, emergency operation centre support manager, said it was 'human error' but breathing difficulties was one of the 'four commandments' of symptoms which should ring alarm bells.
The court heard Ms Charity - a science technician at Lynn Grove Academy - had struggled with chronic pain and self-medicated with alcohol and medication ordered online, alongside prescribed drugs. She also suffered with depression following the breakdown of her marriage. But Ms Charity's sister Andrea Arger said: 'She had been getting back on track.'
The medical cause of death was given as left ventricular hypertrophy. Ms Thompson in a narrative conclusion said: 'The evidence does not reveal whether the delay caused or contributed to [Ms Charity's] death.'
Mrs Arger said the family would pursue civil action, as she believes her sister may have survived with a faster response.
An EEAST spokesperson said: 'Our thoughts are with the family at what is a very difficult time for them, and we thank them for their cooperation with the investigation into what happened.
'The triage of the initial 999 call did not factor in the patient's difficulty in breathing, the software produced an incorrect response priority for patients with particular symptoms associated with abdominal pain, and there was a lack of specific instructions for call handler around call back times.
'The actions from this included reflective practice for the call handler, an internal review of the responding priorities of code sets for any potential local or national changes in relation to abdominal pain, and feedback about the issues to the Academy Clinical Group and Emergency Call Prioritisation Advisory Group (ECPAG) for review.'
Legal aid call for bereaved families
The family's lawyer, David Jones from Morgan Jones Pett solicitors said: 'This is a very tragic case involving the death of a relatively young woman whose family, quite rightly, want answers.
'What this case also highlights is that there is an urgent need for bereaved families to receive legal aid for representation at inquests where public bodies are legally represented. We are representing the family of Jeanette on a pro-bono basis. Without our free support, the family would have no legal representation at this hearing and potentially not get the answers they need.'
The government has come under increasing pressure to ensure families are granted legal aid for inquests. In a report commissioned by the Home Office James Jones, chair of the Hillsborough Independent Panel, said there should be 'an end to public bodies spending limitless sums providing themselves with representation which surpasses that available to families'.
Childhood friend raises nearly £6,000
Close friend Nancy Rouse has raised nearly £6,000 in Ms Charity's memory, by climbing Mount Kilimanjaro to scatter her friend's ashes.
Mother-of-two Ms Rouse took on the gruelling challenge last month to raise money for Barnado's - and called it a final adventure with her friend.
Ms Rouse had known Ms Charity since they were just 11 years old, and attended the inquest into her death yesterday to find answers.
Speaking after the inquest she said: 'We were just very good friends.
'The support I've had for the climb has all been from the community, and with gift aid we've nearly reached the £6,000 total.'
Ms Rouse said she chose to scatter Ms Charity's ashes at the mountain's summit due to her love of nature and animals.
Money was raised through various events, including a quiz night. Donations can still be made by visiting visit www.justgiving.com/fundraising/nancy-rouse
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