Mother-of-six, 32, who drowned after getting trapped in sea defence rocks could have been saved if ambulance service hadn’t ‘muddled’ rescue

A coroner today criticized the ambulance service that presided over a ‘messy’ rescue operation that led to the death of a mother-of-six who was trapped upside down between sea defense rocks at low tide.

Saffron Cole-Nottage, 32, was walking her dog with her daughter when she lost her footing on a slippery concrete pavement and fell headlong over the edge of a cliff in Lowestoft, Suffolk.

The inquest heard that after a passerby called 999 for help, the ambulance service operator failed to detect the rushing tide for seven minutes.

Suffolk Fire and Rescue team was contacted to respond to the incident in just 13 minutes of the call, which started at 19.52 on February 2 last year.

The paramedic, who was the first emergency responder to arrive at the scene, is said to have ignored protocols that clearly stated that rescue and resuscitation must occur within 30 minutes of arrival.

The two-week investigation also heard that there was a lack of communication at the scene and that paramedics and Coastguard members refused to go to Ms Cole-Nottage’s aid because they did not have personal protective equipment.

The hearing was told that the 999 call was also hampered by the East of England Ambulance Service call handler having to blindly follow certain questions, while the first paramedic at the scene should have received more support from the control room.

At today’s hearing, coroner Darren Stewart expressed concern that the call handler even told passers-by to stop trying to save Ms Cole-Nottage by pulling her from the rocks, as he recorded an oral conclusion.

The mother of six children went out to walk her dog with her daughter on February 2 last year.

He said Ms Cole-Nottage ‘died from accidental drowning’.

Explaining that the East of England Ambulance Service ‘did not immediately contact the fire service’, he added: ‘Had Suffolk Fire and Rescue Service been alerted to the incident immediately… it is possible that Saffron could have been pulled from the rocks sooner and survived.’

But he added that it was ‘unlikely’ that he would survive.

The chaotic response to Ms Cole-Nottage’s precarious situation began at 7.52pm, when a young girl called 999 after she chanced upon the incident while out with two friends.

His call was passed on to the East of England Ambulance Service and dealt with by NHS emergency call handler Daniel Joy, who spent four minutes trying to find the exact location of the incident.

He also could not control how fast the tide was coming in and classified it as a ‘trap’.

Call handling team leader Christopher Strutt told the inquest that Mr Joy ‘gave no real sense of urgency’ when he ‘delivered the information’ to him.

He also admitted the ambulance should have contacted Suffolk Fire and Rescue Service within seconds of learning that Ms Cole-Nottage’s head was trapped.

Mr Strutt revealed that an algorithm used by operators in the computer system meant they had to follow a strict set of questions before asking their own; This was criticized by the coroner as ‘quite cumbersome’ adding to the ‘mixed response’.

The extent of the emergency only became clear at 7.59pm (seven minutes into the interview) when the girl reported that Ms Cole-Nottage’s head had gone into the water.

The disturbing recording of the conversation recorded the increasingly exasperated girl saying: ‘How long is it going to take because I think he’s going to die.’

Twelve minutes later he added: ‘Can they come quickly because I think you’re dead?’

A two-man ambulance crew was dispatched from Beccles, approximately 10 miles away, at 7.57pm, but a rapid response ambulance was dispatched at 8.02pm when the danger Ms Cole-Nottage was in was finally clear.

The ambulance service contacted Suffolk Fire and Rescue at 8.05pm and said someone was underwater but casually asked: ‘We’re on our way with the Coastguard and would you like to come along?’

Since the fire department did not routinely go out to sea for rescues, they contacted the Dover Marine Rescue Coordination Center at 8:06 pm and then the Coast Guard Rescue Center at 8:09 pm to notify them that they were needed.

A minute later the ambulance rapid response vehicle arrived at the seashore with paramedic Colleen Gibson.

Inquest heard how ‘messy’ operation followed 999 call

Flowers were left for the tragic mother after her death

He told the inquest his training included learning a 30-minute time limit for rescuing someone after they went underwater.

However, he decided that ‘he was unable to make a rescue at this time as he had been underwater for 20 minutes’.

When asked why she did not inform the Coastguard or the police that there would be a further ten minutes in the critical window, investigating barrister Bridget Dolan KC said: ‘I don’t know.’

Police body camera footage shows an officer arriving a short time later asking him if Ms Cole-Nottage could be rescued and he told them ‘No’.

Expert witness Professor Richard Lyon, a consultant in emergency medicine, told the hearing that the rescue ‘clock’ could only have started from the moment Ms Gibson arrived because eyewitness information could be unreliable.

While full recovery with resuscitation could be expected to occur within five minutes, survival time (albeit possibly resulting in brain damage due to oxygen starvation) extended well beyond that.

Another expert, paramedic Matthew England, who is on a group advising the Home Office on combined emergency services responses, said Ms Gibson, who joined the ambulance service in 2018 and had attended four water incidents, should have taken control of the scene as the first responder there.

He was also supposed to communicate with arriving Coast Guard officers, police and firefighters, but the operation ‘didn’t seem very co-ordinated’.

“I did not see any evidence of a meeting or briefing between the agencies,” he told the inquiry.

In the confusion, firefighters were unaware that the operation was called body extrication and pulled Ms Cole-Nottage from the rocks less than a minute before starting CPR at 8.30pm.

When paramedics refused to bring life-saving equipment to where they would put the body, a firefighter swore at them.

The lack of preparation was further highlighted by Richard Lark, on-call manager at the Suffolk Fire Department, who said ambulance crews did not descend on the rocks because they did not have personal protective equipment (PPE).

The official added that two members of the Coast Guard were also sent to the scene in overalls and without PPE.

Efforts to resuscitate Ms Cole-Nottage, whose legs were still warm, according to Mr Lark, who added that she was able to breathe after being submerged due to a possible gap in the rocks. It was stopped at 20.44.

Paramedic Billy Seaman, who succeeded Ms Gibson, described a ‘disjointed’ operation that was effectively ‘winged’ by responders.

He explained that he had never been involved in a drowning before and that he was required to receive annual training “but was not always given”.

Home Office adviser Mr England also cited systemic failings and said Ms Gibson needed ‘more support from the control room’.

Referring to the first 999 call from which the catalog of errors began, the coroner noted that the words ‘trapped’, ‘stuck’ and ‘stuck’ were all said by the teenager within four minutes.

He added: ‘You don’t have to be a rocket scientist to realize that a single crew couldn’t do much about it.’

The inquest heard Ms Cole-Nottage was drunk on the day of the incident, the equivalent of approximately three times the drink-driving limit.

Prof Lyon said this made him ‘more likely to stumble’ and ‘his ability to push himself out may also have been impaired’.

But Saba Naqshbandi, representing Ms Cole-Nottage’s family, accepted alcohol levels may have been “irrelevant” after the KC said the rocks were “smooth” [meaning] There was no way he could push himself out’.

The coroner described Ms Cole-Nottage, who worked as a cleaner, as a ‘loving mother who was completely devoted to her children’.

The trial continues.