Mother, 29, found dead at home with her two-year-old daughter lying on her chest saying ‘mummy won’t wake up’ died after ‘gross failures’ in care, inquest rules

A coroner has found “gross failures” in the care of a mother who was found dead in her home as 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 doesn’t want to wake up.’

There was a “clear sign” of a cardiac event, coroner Jo Lees said, when two paramedics were called because the patient had been vomiting and had a sore throat.

Upon arrival, paramedics were told the patient was experiencing chest pain, but they reported no concerns after performing an electrocardiogram (ECG) to check Lauren’s heart rhythm and electrical activity.

Ms Lees, area coroner for the Black Country, told the inquest that this was likely to have influenced Lauren’s decision not to go to hospital and that there had been ‘gross failures’ in her care.

However, Ms Lees also said there was not enough evidence to suggest she would have survived if the ECG results had been read correctly.

A post-mortem examination revealed that Lauren died as a result of a sudden heart attack following a blood clot in the lung.

The coroner said she could not conclude that neglect occurred, but did note that Lauren’s abnormal ECG reading was misinterpreted.

Ms Lees said the interpretation of ECG tests was a fundamental part of paramedics’ work, but there were three abnormal indicators that had been overlooked.

Ahead of the inquest at the 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 the West Midland Ambulance Service (WMAS) own investigation found that doctors felt ‘falsely reassured’ that Lauren’s condition was ‘not too worrying’ due to her old age and that she seemed to be doing well.

Her calm demeanor caused medical staff to disbelieve the pain score she gave them, the report found.

The report concluded that the discharge was not safe or appropriate and that doctors had ‘communicated incomplete information about Lauren’s condition to the 911 service’.

At the inquest yesterday, Ms Lees raised concerns about the training at WMAS and said she would set them out in a report on preventing future deaths, which the ambulance service will have to respond to.

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 on the floor of her apartment in Wolverhampton on January 6.

The court heard that ambulance crews were sent to the young mother’s home following a 111 call 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 recognize the signs of an autodiagnostic monitor of “abnormal findings in a woman aged 18 to 39 years.”

Ms Hardwick said when she read her ECG results she saw nothing that concerned her. She told Lauren she could not explain her symptoms and advised her to go to the hospital for further tests.

But she said Lauren had refused.

Mrs 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 had to go.”

Ms Smith told the inquest she had fitted the ECG leads and said there were ‘no obvious problems’.

Matthew Ward, a consultant paramedic and head of clinical practice at WMAS, later reviewed the ECG reading and said it was abnormal and warranted further investigation.

Both paramedics claimed that they had not fully interpreted the ECG reading because there were certain indicators that they had not been trained to pay attention to.

However, Eleanor Ball, head of WMAS patient safety learning, disputed this at the inquest.

She could not answer whether the ambulance service had determined whether either paramedic needed additional training after the incident, but said doctors could contact the training department for further training if they felt it was necessary.

The court in Oldbury, West Midlands, heard that when Mrs 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 that it was “heartbreaking” to know Lauren’s daughter would grow up without a mother.

Speaking after the inquest, Mrs 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 lawyer Manby Bowdler said: ‘The conclusions of the (WMAS) investigation show that Lauren’s symptoms were not appreciated and that the paramedics were wrongly 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 has 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 very important to us that these are implemented thoroughly, competently and quickly to ensure no more avoidable deaths occur in their care.’

Ahead of the inquest, WMAS apologized to the Smith family and said it was “committed to doing everything possible to prevent something like this from ever happening again.”