A coroner has found “gross failures” in the care of a mother found dead at home with her toddler trying to wake her – just hours after paramedics were sent to her.
Lauren Page Smith, 29, was discovered lying on the floor with her two-year-old daughter lying on her chest saying “mommy won’t wake up”.
There was a “clear sign” of a cardiac event in progress, coroner Jo Lees said, when two paramedics were called because the patient had been vomiting and had a sore throat.
Upon arrival, the ambulance crew was informed that the patient was suffering from chest pain, but reported no problems after performing an electrocardiogram (ECG) to check Lauren’s heart rate and electrical activity.
Ms Lees, coroner for the Black Country, told the inquest it was likely this affected Lauren’s decision not to go to hospital and that there were “failures blatant” in his care.
Lauren Page Smith (pictured), 29, was found at her home in Wolverhampton by her mother in January, lying on the floor with her two-year-old daughter on her chest.
Pictured: Lauren with her two-year-old daughter before her death. Her mother said “Lauren had her whole life ahead of her”
However, Ms Lees also said there was not enough evidence to suggest she would have survived if the ECG results had been read correctly.
An autopsy showed that Lauren died of a sudden heart attack following a blood clot in her lung.
The coroner said she was unable to find negligence but, in delivering a narrative conclusion, noted that Lauren’s abnormal ECG reading had been misinterpreted.
Ms Lees said interpreting ECG tests was a fundamental part of paramedics’ work, but three abnormal indicators had been missed.
Ahead of the inquest at Black Country Coroner’s Court, lawyers for the family told MailOnline the two paramedics had ‘a significant gap in their training’.
They spoke out after West Midland Ambulance Service’s (WMAS) own investigation found clinicians felt “falsely reassured” that Lauren’s condition was “not too concerning” due to her age and that she seemed fine.
Her calm demeanor meant medical staff did not believe the pain score she gave them, the report said.
The report concluded that the discharge was neither safe nor appropriate and that clinicians “passed incomplete information to the 111 service about Lauren’s condition”.
At yesterday’s inquest, Ms Lees raised concerns about WMAS training and said she would outline them in a report on preventing future deaths, which the ambulance service will be obliged to respond to .
Lauren (pictured) had called 111 for advice and paramedics arrived at her home and carried out brief assessments.
Law firm FBC Manby Bowdler, which represents the Smith family, said it was concerned that paramedics from the West Midlands Ambulance Service had misinterpreted Lauren’s ECG readings and told her that she was fine instead of taking him to the hospital. (Image from file)
She said she would also report the two paramedics who attended the scene to the Health and Care Professions Council.
The inquest heard that Lauren’s mother, Emma Carrington, found her daughter lying on the floor in her Wolverhampton flat on January 6.
The court heard that paramedics were dispatched to the young mother’s home following a call to 111 for advice.
Ambulance technician Jodie Hardwick and her senior colleague and paramedic Laura Smith carried out an ECG test. But they misinterpreted the results and failed to spot signs on a self-diagnostic monitor indicating “abnormal results for a female 18 to 39 years old.”
Ms Hardwick said when she read her ECG results she saw nothing that worried her and told Lauren she couldn’t explain her symptoms, advising her to go to hospital for further tests .
But she said Lauren refused.
Ms Hardwick said: “When I advised her to go she said she had seen on the news how busy the hospitals were.
“I got the general impression that she didn’t feel like she needed to go.”
Ms Smith told the inquest she had applied the ECG leads and said there were “no clear issues”.
Matthew Ward, consultant paramedic and head of clinical practice at WMAS, then reviewed the ECG reading and said it was abnormal and warranted further investigation.
Both paramedics claimed they did not fully interpret the ECG results because they were not trained to monitor certain indicators.
However, Eleanor Ball, head of patient safety learning at WMAS, disputed this at the inquest.
She could not answer whether the ambulance service had determined whether the two paramedics needed additional training after the incident, but said clinicians could contact the training service for additional training if needed. they considered it necessary.
Oldbury Crown Court, in the West Midlands, heard that when Ms Carrington later arrived at the address she attempted to resuscitate Lauren with CPR.
In a statement read by the coroner, the grieving mother said she could not explain the pain she felt and knowing Lauren’s daughter would grow up without a mother was “heartbreaking”.
Speaking after the conclusion of the inquest, Ms Carrington said her “beautiful daughter” had been “abandoned by two paramedics”.
Michael Portman-Hann, a partner at the law firm representing the Smith family, told MailOnline last week that “extensive” improvements were needed to avoid a repeat of the “truly tragic case”.
FBC lawyer Manby Bowdler said: “The findings of the investigation (WMAS) demonstrate that Lauren’s symptoms were not appreciated and the paramedics were falsely reassured, but also that there was a significant gap in their training and skills.
“Lauren’s family and I have a number of concerns about the care Lauren received, but also about the wider implications for future patients of the ambulance service.
“The Service recognizes that improvements need to be made, and it is really important to us that these are implemented thoroughly, competently and quickly to ensure that no avoidable deaths occur in their care.”
Before the investigation, WMAS apologized to the Smith family and said they were “determined to do everything possible to try to prevent something like this from happening again.”