Baby died after 999 crews 'chaos'
A coroner has described ambulance crews as "chaotic" after hearing a baby girl died when one vehicle got lost and another stopped for petrol while answering a 999 call.
Three-month-old Bella Hellings died in hospital after she suffered a fit and stopped breathing at her home in Thetford, Norfolk.
Coroner William Armstrong said she would have stood a better chance of survival had paramedics not taken 26 minutes - more than three times longer than national targets dictate - to arrive.
Mr Armstrong described Bella as a "star which will always shine" adding: "She will never grow up, she will never lose her innocence, she will always be loved."
After the inquest the East of England Ambulance Trust apologised for the delays and said steps had been taken to avoid future tragedies.
But Bella's parents, Amy Carter and Scott Hellings, said they were considering civil action against the trust.
They said: "We will always believe in our hearts that Bella was let down by the health services when she was at her most vulnerable and when she needed help the most."
Speaking in the inquest at Norfolk Coroner's Court, Miss Carter said: "She was really cheeky and smiley.
"If you were having a bad day and you walked in to the room, all she had to do was smile and she would brighten the day up."
The inquest heard an emergency first response car had been immediately dispatched from a mile away following the call at 11.09am on March 3.
The driver struggled to find the new-build house because the trust's satellite navigation system was not up-to-date and " there were too many blue doors".
An ambulance which was travelling on the nearby A11 was also diverted from another incident but this was low on fuel and had to stop for up to five minutes at a BP forecourt.
Controllers failed to tell the paramedics that an air ambulance had also been dispatched.
If they had known they were not needed to take the child to hospital they would not stopped to refuel and could have arrived sooner to administer care at the scene, the inquest heard.
Mr Armstrong recorded a narrative conclusion that the baby died at West Suffolk Hospital, Bury St Edmunds, from congenital heart disease after delays in medical assistance which reduced her prospects of survival.
He added: "By anyone's standard this was a grave emergency - what happened here was a long, long way from the eight minute response target.
"The delay in giving Bella the care that she needed was wholly indefensible.
"There was a catalogue of catastrophes and a chaotic response."
Bella, who had been born five weeks premature, had a history of health scares and ambulance crews had visited the house without any delays on two previous occasions.
John Martin, interim director of clinical quality at the East of England Ambulance Service NHS Trust, said: "The trust's response to Bella was delayed for a number of factors, primarily the difficulty in locating the address due to it being a new build.
"As a result, a number of specific measures h ave now been put in place, and the trust has raised the problems of the delay in new buildings and developments appearing on maps and sat nav systems on a national level.
"In addition, the trust is recruiting more frontline staff and getting more ambulances on the road in order to improve our service for patients."
National guidelines state that an emergency response vehicle should reach 75% of patients deemed to be in a life-threatening condition within eight minutes.