Coroner raises concerns over emergency call delays after inquest into the death of three-day-old baby

Wyllow-Raine's mother Amelia-Jayne Pill waited for eight minutes for her 999 call to be connected to the South Central Ambulance Service in the early hours of 30 September 2022, before waiting a further 31 minutes for the first paramedic to arrive.

At 05.26am, an ambulance crew took Wyllow-Raine to John Radcliffe Hospital in Oxford, arriving at 05.52am, and she was pronounced dead not long after her arrival at 06.02am.

 At an inquest into her death in December 2024, Senior Coroner Darren Salter found that the 31-minute wait time for an ambulance had not directly contributed to Wyllow-Raine's death.

However, a Prevention of Future Deaths (PFD) report was issued earlier this month, Mr Salter raised his concerns over the delay in connecting to an ECT (Emergency Call Taker), and the length of time for an ambulance or paramedic to attend.

Writing to South Central Ambulance Service, Mr Salter said:

"I realise there will be occasions when ambulance resources, particularly in the early hours when there are fewer resources, happen to be located in a different area leading to prolonged response times.

“It would seem that the issue of the delay in being connected to an ECT is more amenable to a systems improvement, particularly when one considers that arrangements are in place for calls to default to other ambulance services who may be less busy or who have greater capacity.

“Given the risk associated with delayed response times, particularly in connecting to an ECT, I request that the concerns I have raised are considered and that you respond thereafter.”

He added:

"I would be interested to learn if actions identified as part of South Central Ambulance Service's (SCAS) own internal review have been fully implemented and are subject to auditing to ensure compliance.

“In my opinion action should be taken to prevent future deaths and I believe you South Central Ambulance Service has the power to take such action.”

Medical negligence partner and head of department Suzanne White said:

“This report highlights how crucial each minute is in medical emergencies. When there are limited resources, especially within ambulance services, it is vital that there are careful measures in place to ensure that families in potentially fatal situations receive urgent care. It is important that the coroner’s concerns and recommendations are actioned to ensure that no other family will have to experience the distress and pain that Wyllow-Raine’s family has been through”.

Amelia-Jayne Pill said:

“While nothing can bring back Wyllow-Raine, we hope the coroner’s recommendations are taken on board and that when there are future situations with lower staffing than usual, there are measures put in place to prevent delayed response times and to ensure that patients receive emergency care as quick as possible.

“I hope that changes are made within the emergency services to reduce the risk of families having to experience the fear and understanding that we faced when we realised that help may be too far away.

“I hope that no one has to undergo the events that we experienced as a family during the early hours of the morning of Wyllow-Raine’s devastating death.”