Inquest finds 999 delay not a factor in infant’s death

An inquest has concluded that delays in ambulance response did not cause the death of a newborn infant, even though her family experienced an “awful” wait during a 999 emergency call. Wyllow-Raine Swinburn became unwell on September 30, 2022, and passed away soon after being admitted to the John Radcliffe Hospital in Oxford. The inquiry into her passing revealed that her mother waited eight minutes for a 999 call to be answered, followed by an additional 30-minute wait for an ambulance to reach their Didcot residence. Coroner Darren Salter issued a narrative conclusion at Oxfordshire Coroner’s Court. The inquest was informed that Wyllow-Raine was born by caesarean section on September 27. She weighed 10lbs 5oz and seemed to be in good health. Previously submitted evidence from grandmother Anna Fisher stated that three days later, the baby was crying when put to bed at the family’s Didcot, Oxfordshire, home. The hearing was informed that Wyllow-Raine’s mother, Amelia Pill, had contacted her in the early morning of September 30, 2022, reporting that the baby seemed not to be breathing. Her statement detailed Ms Pill “shouting down the phone and begging for someone to answer” while she remained on the line after calling 999. Karen Sillicorn-Aston, the clinical governance lead for South Central Ambulance Service (SCAS), testified that the call was placed at 04:38 BST and was disconnected eight minutes later by a BT operator, whose role involves monitoring all calls before they are answered. She explained that regulations mandated the BT operator to transfer the call to an alternative service, specifically the East of England Ambulance Service, and that the family stayed on the line for an additional two minutes before the call was picked up. The inquest learned that, according to SCAS, ambulances were expected to arrive within seven minutes in 90% of incidents, and at the time of the call, “demand [for ambulance crews] was outstripping resource.” The hearing was also told that by the time an ambulance reached the location, the baby’s body temperature had dropped to 30.8C. Ms Sillicorn-Aston further stated that new protocols have been implemented to enhance communication between BT call handlers and ambulance services, as well as to decrease waiting periods. Mr. Salter announced his intention to write to both SCAS and BT, requesting a review of waiting times and call-handling procedures, noting that the family’s wait was “far too long.” Ms. Sillicorn-Aston characterized the family’s telephone wait as “awful.” Nevertheless, Professor Simon Mitchell, an independent consultant specializing in neo-natal medicine, informed the inquest that it was “probable” the ambulance delay did not play a role in Wyllow-Raine’s death. He further stated that, in his professional judgment, Wyllow-Raine succumbed to “probable congenital hyperinsulinism and hypoglycaemia leading to cardio-respiratory arrest.” Professor Richard Lyon, an emergency department consultant, indicated in a statement that Wyllow-Raine’s chances of survival following cardiac arrest were probably less than 1%, and an earlier ambulance arrival would not have enhanced these odds. Mr. Salter officially recorded a narrative verdict, attributing the cause of death to “congenital hyperinsulinism and hypoglycaemia leading to cardio-respiratory arrest.” In a statement, Ms. Pill expressed: “Even though Wyllow-Raine was only here for a small moment in time, she will always mean the world to me.” She characterized her death as a “nightmare I can’t wake up from” and stated that there would “always be an empty seat at our dinner table and a hole missing in our family’s hearts.” She further added: “I tend to lay hard on the darker moments, as almost all grief-stricken individuals do, but Wyllow-Raine will always deserve more than that moment, she deserves to be remembered for all her magical moments too.”