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Mother begged doctors to save baby

A mother "begged" doctors to save her four-month-old baby after ambulance staff failed to treat her as an emergency, an inquest heard.

Lacey-Marie Poton collapsed just ten minutes after returning home with her parents following a heart procedure at Bristol Royal Hospital for Children the previous day.

Her mother, Emma Norley, 21, performed CPR while an ambulance travelled to the property in Fishponds, Bristol, in July 2013.

Paramedics arrived six minutes later and decided to take Lacey-Marie, who was "pale, mottled and floppy", to the hospital's emergency department.

The crew failed to recognise the baby's "time critical" condition and so travelled at normal speed without blue lights or alerting hospital staff of their impending arrival.

Lacey-Marie's condition rapidly deteriorated after she reached Bristol Royal Hospital for Children and she died in her mother's arms about four hours later.

The inquest into her death, at Avon Coroner's Court in Flax Bourton, near Bristol, is the seventh to take place concerning the care of child cardiac patients at the hospital.

Miss Norley, who is now pregnant with her second child, said in a statement to the hearing that she called 999 just 10 minutes after arriving home on July 27 2013.

"The ambulance arrived within 10 minutes and the paramedics did not think there was anything wrong with Lacey-Marie," she said.

"I told them I had just performed CPR but they did not seem to understand why I had had to.

"Despite having told the operator on the phone that the patient was a baby, the ambulance did not seem to be properly equipped.

"She was not treated as an emergency and no blue light was used throughout the journey even though Lacey-Marie was still crying and grunting."

Miss Norley described how Lacey-Marie required CPR and was transferred to the intensive care ward, where she was given a 50% chance of survival.

"I was crying my eyes out and begged him (a cardiologist) to save her," Miss Norley said. "I ran in to intensive care and held Lacey-Marie in my arms as she passed away."

A post mortem examination could not find an exact cause of death for Lacey-Marie but concluded it was due to congenital heart disease and Down's Syndrome.

Lacey-Marie was born on March 24 2013 at 34 weeks, weighing 4lb 11oz, and diagnosed with heart condition Tetralogy of Fallot aged five weeks.

She underwent three procedures, the final one a catheterisation and stent to improve blood flow to her lungs, on July 25.

The following day Lacey-Marie was vomiting frequently but her parents, Miss Norley and Jhonny Poton, were advised it was a side effect of the anaesthetic, the inquest heard.

Lacey-Marie was discharged on July 26 but became "shivering, shaking and pale" on the journey home.

Her parents reported this to the hospital but claim they were told it was "nothing to worry about" and were advised to book an appointment with their GP.

A receptionist refused to schedule an appointment as the baby appeared too unwell and she was taken back to Bristol Royal Hospital for Children.

Paediatric cardiologist Tatjana Rjabova informed the parents Lacey-Marie had gastroenteritis and could return home with Dioralyte.

Just 10 minutes after reaching their home, Lacey-Marie went into a cardiac arrest and Miss Norley had to perform CPR, the inquest was told.

An internal report by South Western Ambulance Service found "the crew did not recognise the time-critical nature of the baby and therefore conveyed the patient at normal road speed without a pre-alert to the hospital".

Paramedic Kevin Brown told the hearing he felt using blue lights may have only reduced the five-mile journey, which took 22 minutes and 19 seconds, by "one to two minutes".

"The blue lights were not on but the ambulance was not going slowly," Adrian South, deputy clinical director of South Western Ambulance Service, said.

Paramedic Nicholas Stock described how Lacey-Marie was "rather floppy" and "pale and mottled" but Miss Norley assured him this was her usual condition.

"A patient with cardiac history with a query cardiac arrest that is pale and floppy should be blue lighted to the ED," Mr Stock, who has since received further training, told the inquest.

"I appreciate there has been talk that blue lights wouldn't have made much of a difference but they would have made some difference so that should have been done."

Mark Lyttle, consultant in paediatric emergency medicine, said the hospital could have prepared experts, drugs and extra staff if it had received a pre-alert Lacey-Marie was coming.

Andrew Tometzki, lead consultant in paediatric cardiology, told the hearing it was unclear what had caused Lacey-Marie's death.

"I can't explain her death," Dr Tometzki said. "That's very upsetting and most people would want to know why a patient died."

Avon coroner Maria Voisin adjourned the inquest until 11am tomorrow.

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