Ambulance delays and failures to upgrade the urgency of a 999 call contributed to a woman’s death, an inquest has concluded.

Donna Georgina Smith died aged 51 in 2021 after an ambulance took 48 minutes longer than average to arrive.

An inquest at Teesside Coroner’s Court heard Donna went for a lie down after feeling lightheaded before collapsing to the floor holding her chest 10 minutes later.

She told her husband she was having a heart attack and he called 999 at 3pm. The call was categorised as a ‘category two’ urgency, meaning an ambulance arrives, on average, in 18 minutes.

The inquest earlier this month heard Donna’s family chased the ambulance service (NEAS) and even rang police and the fire brigade for help, both of whom rang NEAS and were told an ambulance would be attending.

A clinician rang the family for an update on her condition at 3.37pm but did not re-categorise the call, and instead asked if the family could take her to hospital.

An ambulance didn’t arrive for another hour and six minutes, at 4.06pm, and with no sirens.

By the time it arrived fire crews had helped the family get Donna on a stretcher and into a family member’s car. The fire brigade flagged down the ambulance before she was transferred over to paramedics’ care.

Donna arrived at James Cook University Hospital in Middlesbrough at 5.14pm that day - July 17, 2021 – but was pronounced dead soon after.

The ambulance service accepted the call should have been recategorized as a ‘category one’ call when the clinician rang and said the call handler’s questioning was insufficient to ascertain her condition.

She had been in peri-arrest, the period just before or after full cardiac arrest, a life-threatening state for 10 minutes before the clinician rang, the inquest heard.

If the call had been upgraded an ambulance would have arrived in, on average, seven minutes.

Coroner Clare Bailey said: “The failure to recognise this deterioration and act accordingly also contributed to Donna’s death.

“Neither the call handler nor the computer recognised the significant change in Donna’s health when the family called at 3.26pm. She was in peri-arrest and the call should have been re- categorised as a ‘category one’ dispatch.

“There were missed opportunities on behalf of the ambulance service to recognise that Donna was peri arrest and in turn upgrade the call category.

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“The failure to upgrade the call category and the delay in the ambulance contributed to Donna’s death.”

Miss Bailey, the Senior Coroner for Teesside and Hartlepool, added: “In my opinion there is a risk that future deaths could occur unless action is taken.”

The coroner has filed a prevention of future deaths report to the Department of Health and Social Care (DHSC) and North East Ambulance Service. Both are under a duty to respond within 56 days explaining action taken or proposed to prevent another death in similar circumstances.