Paramedics and police sent to help a mother who became trapped headfirst under water should not have assumed she was dead when they arrived, an expert has told an inquest.
Emergency services were sent to the seafront in Lowestoft, Suffolk, following reports that Saffron Cole-Nottage, 32, had fallen and become wedged between sea defence rocks as the tide came in.
The hearing in Ipswich has already been told that the first emergency responder to arrive, paramedic Colleen Gibson, failed to tell other rescuers the mother-of-six could be saved.
Giving evidence today, pre-hospital emergency care specialist Professor Richard Lyons said none of those sent to assist Ms Cole-Nottage followed guidelines that state 30 minutes of rescue efforts should begin when the first person arrives, regardless of reports of when submersion occurred.
‘I would expect an ambulance crew to have that 30-minute initial rescue time in their mind…’ Prof Lyons told the inquest.
‘Knowing that the clock starts when they arrive and that 30-minute revival period would be the minimum – I would expect the ambulance crews to be aware.’
He added: ‘The guidance is clear that the clock starts when the first responder arrives.
‘The only purpose of the guidance is to maximise the chance of a successful rescue attempt.
Emergency services were sent to the seafront in Lowestoft, Suffolk, following reports that Saffron Cole-Nottage, 32, had fallen and become wedged between sea defence rocks as the tide came in
‘We accept that the time is likely to be after the submersion time but the point is it’s a confirmed time that will not be ambiguous and is free of the error of bystander reporting.’
The inquest has heard how Ms Cole-Nottage became stuck between the rocks on the evening of February 2 last year as she walked a dog with her daughter.
A teenage girl who was with two friends called 999 at 7.52pm but it was not until seven minutes later that the call handler established the tide was coming in fast after being told Ms Cole-Nottage’s head was going under the water.
Paramedic Ms Gibson arrived at 8.10pm and looked over the railings. She went down to the rocks with police who arrived at 8.13pm and decided she was dead.
Amid the apparently chaotic handling of the incident, firefighters who arrived shortly afterwards were unaware that Ms Cole-Nottage had been declared dead and pulled her out within a minute.
Prof Lyons said that when someone becomes submerged, survival is ‘probable’ if they are removed and given CPR within the first five minutes.
From around ten minutes the ‘brain is invariably affected’ and ‘beyond 25 minutes, survival would not have been possible’.
He pointed out there was a chance that Ms Cole-Nottage’s head was in an air pocket, which would have increased her survival time.
The mother-of-six was walking her dog with her daughter when she became stuck upside down on February 2 last year
Pre-hospital emergency care specialist Professor Richard Lyons said none of those sent to assist Ms Cole-Nottage followed guidelines that state 30 minutes of rescue efforts should begin when the first person arrives
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Ms Cole-Nottage had been drinking on the day of the incident and was the equivalent of around three times the drink-drive limit, the inquest has been told.
Prof Lyons said this may have made her ‘more likely to stumble’ and her ability to ‘push herself out would have been impaired as well’.
But Saba Naqshbandi KC, representing Ms Cole-Nottage’s family, said: ‘The rocks were smooth. There were no means by which she could have pushed herself out.’
Prof Lyons replied: ‘If she was physically so trapped it [alcohol levels] would be irrelevant because of the geography of the rocks.’
He concluded that police and other emergency responders need better awareness that a rescue should take place in situations similar to Ms Cole-Nottage’s.
‘There was a wrong decision [on this occasion] and this was carried through the train,’ he said.
‘Any responder can arrive on the scene and they should go in with the mindset of “Start the clock for the rescue”.’
A 999 operator failed to realise the risk posed by the rising tide until the caller said seven minutes into the conversation that Ms Cole-Nottage’s head was becoming submerged
Floral tributes left at the spot where Ms Cole-Nottage died
During questioning yesterday, Ms Gibson was asked by inquest barrister Bridget Dolan KC why she didn’t tell police, firefighters and Coastguard personnel about the potential opportunity to save her patient’s life.
She replied: ‘I don’t know.’
Ms Dolan added that the police officers would have tried to rescue Ms Cole-Nottage had they known she could be saved.
But Ms Gibson said: ‘I don’t believe that to be safe. I wouldn’t be able to reach down into the rocks head-first with the water.’
The paramedic added she had been involved in four previous potential drowning incidents but had never been trained to take charge of a multi-agency emergency.
Matthew England, a nurse and paramedic who sits on a group that advises the Home Office about emergency services working together on incidents, also told the hearing that Ms Gibson should have had ‘more support from the control room’.
Another paramedic previously told the hearing that other emergency responders were effectively ‘winging it’ during the ‘disjointed’ operation.
There has also been evidence of a lack of communication between the different agencies at the scene, meaning it ‘did not appear very coordinated’.
Questions have also been asked about an algorithm 999 call handlers have to follow, which requires them to ask questions prompted by their computer and discourages then from posing their own until they have completed the list.
Coroner Darren Stewart suggested the system was ‘rather clunky’ and had led to ‘a muddled response’.
Prof Lyons said today that a working group was looking at ways to speed up how quickly operators can ask callers what time someone’s head became submerged under water.
The inquest continues.
