A coroner has found “gross failings” in the care of a mother who was found dead in her home while her toddler tried 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 on her chest, saying: “Mommy ain’t waking up.”
Coroner Jo Lees said there was a “clear sign” of a cardiovascular event when two paramedics were called because the patient was vomiting and had a sore throat.
On arrival, the ambulance team was informed that the patient was suffering from chest pain. However, after performing an electrocardiogram (EKG) to check Lauren’s heart rhythm and electrical activity, they reported no concerns.
Ms Lees, coroner for the Black Country, told the inquest it was likely that this had influenced Lauren’s decision not to go to hospital and that there had been “gross failings” in her care.
An autopsy revealed that Lauren died of a sudden heart attack caused by a blood clot in her lungs.
Lauren (pictured) had called 111 asking for advice and paramedics arrived at her home and carried out brief checks
Pictured: Lauren with her two-year-old daughter before her death. Her mother said: “Lauren had her whole life ahead of her”
Lauren Page Smith (pictured), 29, was found by her mother in her Wolverhampton home in January, lying on the floor with her two-year-old daughter on her chest
However, Ms Lees also said there was not enough evidence to suggest she would have survived had the ECG results been read correctly.
The coroner said she was unable to determine neglect, but noted in her narrative conclusion that Lauren’s abnormal EKG 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 the Black Country Coroner’s Court, lawyers for the family told MailOnline that the two paramedics had “a significant gap in their training”.
They spoke out after West Midland Ambulance Service’s (WMAS) own investigation found that doctors were “incorrectly convinced” that Lauren’s condition was “not unduly concerning” due to her age and that she appeared to be doing well go.
Her calm demeanor caused medical staff to not believe the pain score she gave them, the report said.
The report concluded that the discharge was neither safe nor appropriate and that doctors “provided 911 with incomplete information about Lauren’s condition.”
At the inquest yesterday, Ms Lees raised concerns about training at WMAS and said she would set these out in a report on preventing future deaths to which the ambulance service would have to respond.
Law firm FBC Manby Bowdler, representing the Smith family, said it was concerned that West Midlands Ambulance Service paramedics misinterpreted Lauren’s ECG readings and told her she was fine rather than taking her to hospital. (file image)
She said she would also report the two paramedics who attended the scene to the Health and Care Professions Council.
The inquest heard 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 sent to the young mother’s home after an emergency call to 111.
Paramedic Jodie Hardwick and her senior colleague and paramedic Laura Smith carried out an ECG test. But they misinterpreted the results and failed to recognize the signs of an automated diagnostic monitor for “abnormal findings in an 18- to 39-year-old female.”
Ms Hardwick said when she read her ECG results she saw nothing to cause her concern and told Lauren she could not explain her symptoms and advised her to go to hospital for further tests.
But she said Lauren declined.
Ms Hardwick said: “When I advised her to go there she said she had seen on the news how busy the hospitals were.”
“My general impression was that she didn’t feel like she had to leave.”
Ms Smith told the inquest she placed the ECG leads and said there were “no clear issues”.
Matthew Ward, a consultant paramedic and clinical practice manager at WMAS, later checked the ECG reading and said it was abnormal and required further investigation.
Both paramedics claimed they did not fully interpret the EKG reading because there were certain indicators they were not supposed to pay attention to.
However, WMAS head of patient safety learning Eleanor Ball denied this at the inquest.
She could not answer whether EMS had determined whether both paramedics needed additional training following the incident, but said clinicians could contact the training department for further training if they felt it was needed.
The court in Oldbury, West Midlands, heard that when Ms Carrington later arrived at the address she tried to revive Lauren with CPR.
In a statement read out by the coroner, the grieving mother said she could not explain the pain she felt and it was “heartbreaking” to know Lauren’s daughter would grow up without a mother.
After the inquest concluded, Ms Carrington said her “beautiful daughter” had been “abandoned by two paramedics”.
Michael Portman-Hann, an associate at the law firm representing the Smith family, told MailOnline last week that “thorough” improvements were needed to prevent a repeat of the “truly tragic case”.
FBC’s lawyer Manby Bowdler said: “The conclusions of the (WMAS) investigation show that Lauren’s symptoms were not acknowledged and the paramedics were falsely reassured, but also that there was a significant gap in her training and skills.”
“Lauren’s family and I have a number of concerns about the care Lauren received, but also about the wider impact of the ambulance service on future patients.”
“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 there are no more preventable deaths in its care.”
Ahead of the investigation, WMAS apologized to the Smith family and said it was “determined to do everything we can to prevent something like this from ever happening again.”