'Gross failures' in ambulance service's care of mother found dead at her Wolverhampton home

Lauren Page Smith was discovered lying on the floor with her two-year-old daughter on her chest on January 6 this year.

Today, two paramedics from West Midlands Ambulance Service (WMAS) told an inquest into the 29-year-old's death how they had responded to a call after Lauren complained about vomiting and a sore throat, and were also told she had chest pain when they arrived.

The inquest at Black Country Coroner’s Court in Oldbury heard that they carried out an electrocardiogram (ECG) test to check her heart's rhythm and electrical activity, but misinterpreted the results and failed to spot the signs from an auto diagnostic monitor of ‘abnormal findings for an 18-39 female’, suggesting she was having a heart attack.

A post-mortem examination showed that Lauren died because of a sudden heart attack following a blood clot in the lung.

Coroner Jo Lees said it was clear Lauren had been a "much-loved daughter" and "devoted mother".

She said the interpretation of ECG tests was a fundamental part of the job for paramedics but there were three abnormal indicators which had been missed.

There was a 'clear sign' of a cardiac event in progress, Ms Lees said, despite paramedics reporting no concerns regarding Lauren's readings.

She told the inquest it was likely this had affected Lauren's decision not to attend hospital and there had been "gross failures" in her care.

However, Ms Lees also said there was not enough evidence to suggest she would have survived had the ECG results been read correctly.

The coroner said she was unable to reach a finding of neglect but, delivering a narrative conclusion, she noted Lauren's abnormal ECG reading being incorrectly interpreted.

Ms Lees also raised concerns surrounding training at WMAS and said she would be outlining them in a prevention of future deaths report, which the ambulance service will be forced to respond to.

She said she would also be reporting the two paramedics who had attended the scene to The Health and Care Professions Council.

The inquest heard that Lauren's mother Emma Carrington had found her daughter lying on the floor at her apartment.

Her two-year-old daughter was found lying on her chest saying "mummy won't wake up", and Ms Carrington tried to revive Lauren with CPR.

A statement from Ms Carrington, read by the coroner, said she couldn't explain the pain she felt and to know Lauren's daughter would grow up without a mother was "heartbreaking".

A WMAS investigation found that clinicians felt "falsely reassured" that Lauren’s condition was "not overly concerning" because of her age and that she appeared well, and that her calm demeanour meant that the clinicians did not believe the pain score she provided.

The report concluded that the way the 29-year-old's case was handled on the first attendance was not appropriate, the discharge was not safe or appropriate and that the clinicians "conveyed incomplete information to the 111 service about Lauren’s condition".

Today's inquest was told how ambulance technician Jodie Hardwick and her senior colleague and paramedic Laura Smith had been dispatched to the young mother's home following a 111 call.

Ms Hardwick said when she read her ECG results she saw nothing to give her cause for concern and told Lauren she couldn’t explain her symptoms, advising her to go to hospital for further tests.

But she said that Lauren had declined.

Ms Hardwick said: “When I advised her to go she said she saw on the news how busy hospitals were.

“I got the general impression she didn’t feel like she needed to go.”

Ms Smith told the inquest she had applied the ECG leads and said there were 'no clear issues'.

Matthew Ward, a consultant paramedic and head of clinical practice at WMAS, later reviewed the ECG reading and said it had been abnormal and warranted further investigation.

Both paramedics claimed they had not fully interpreted the ECG reading as there were certain indicators they had not been trained to look out for.

However, WMAS patient safety learning lead Eleanor Ball disputed this at the inquest.

She could not answer if the ambulance service had identified whether both paramedics required additional training following the incident, but said clinicians could contact the training department for further training if it was something they felt was needed.

Speaking after the conclusion of the inquest, Ms Carrington said her 'beautiful daughter' had been 'let down by two paramedics'.

Prior to today's hearing, WMAS had apologised to Lauren's family.

A spokesman said: “The trust carried out a full investigation into what happened to see what learning could be taken from such a tragic case.

"We are determined to do everything possible to try and stop something like this ever happening again.

“The review made a number of recommendations which have been implemented, including providing additional learning to our clinicians about recognising acute coronary syndrome, particularly in women."