A teenager with learning difficulties would not have died if an ambulance had been sent to her home following a 999 call made three months before her body was found, a coroner has said.
The bodies of Loraine Choulla, aged 18, and her mother Alphonsine Djiako Leuga were both discovered on May 21 last year at their home in Hartley Road, Radford, Nottingham.
A week-long inquest heard that Loraine, who had Down’s syndrome, was “entirely dependent” on her mother, who had made a 999 call giving her address and postcode and asking for help on February 2 last year, while feeling unwell.
During the 999 call, made shortly after 1pm on February 2, Ms Leuga groaned, requested an ambulance and said “I need help to my daughter” and “I’m in the bed, I feel cold and can’t move” before cutting off the line.
East Midlands Ambulance Service (EMAS) did not send an ambulance to the address after the call was wrongly classed as being abandoned by the caller, the inquest at Nottingham Coroner’s Court was told.
Summing up the evidence and recording her conclusion on Friday, Nottingham Assistant Coroner Amanda Bewley said 47-year-old Ms Leuga, who born in Cameroon, had frequently refused to answer calls and had gone away for periods of longer than a month.
The coroner said she was “astonished” that Ms Leuga and her daughter were found after a member of the public contacted police after noticing he had not seen them for a lengthy period, rather than by professionals between February and May.
After adding that the city council’s adult social care department had “missed opportunities to intervene” and potentially secure a different outcome, the coroner added: “I am entirely satisfied that had EMAS sent an ambulance to Alphonsine that Loraine would not have died when she died.
“She would most probably still be alive.
“I am clear that Alphonsine died first and Loraine died afterwards.”
Ms Leuga died from pneumonia between February 2 and February 8, the coroner recorded, while Loraine had died from dehydration and malnutrition and “survived her mother by three weeks or more”.
The coroner added that she was “confident to a point of near certainty” that had an ambulance been sent to the address on February 2, Loraine would have been discovered and arrangements made for her needs to be met.
The inquest was told that Ms Leuga was admitted to hospital for a blood transfusion in late January last year as she was critically ill with very low iron levels, and was given a “pragmatic” discharge linked to her daughter’s care needs.
Pathologist Dr Stuart Hamilton told the hearing by video-link that the mother and daughter were both likely to have been dead for “weeks to months” before they were found, rather than for days or hours.
Dr Hamilton said his initial cause of death following a post-mortem examination on Ms Leuga was pneumonia of uncertain cause, while her daughter’s cause of death could not be established.
Answering questions from the coroner, the pathologist said he could not rule out that Ms Leuga had died on the day of the 999 call.
The body of Loraine, who was born in Italy, showed no evidence of any third party involvement.
Dr Hamilton said of the teenager: “Unfortunately, based on the post-mortem examination and additional tests alone, it is my view that the cause of death is classed as unascertained – that is, I am not able to give a cause of death on the balance of probabilities.”
In a statement issued after the inquest, Keeley Sheldon, director of quality at EMAS, said: “I am truly sorry that we did not respond as we should have to Alphonsine Djiako Leuga and Loraine Choulla.
“Our deepest condolences remain with their family.
“We fully accept the coroner’s findings. After our internal investigation, we made changes to our policies, procedures and training to ensure this does not happen in future.”
