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26 September 2013, 15:25 | Updated: 26 September 2013, 16:22
A baby girl died in Norfolk after one emergency vehicle got lost and another stopped for petrol as they answered a 999 call, an inquest has heard.
Three-month-old Bella Hellings died at hospital after she suffered a fit and stopped breathing at her home in Thetford.
Paramedics took 26 minutes - more than three times longer than national targets dictate - to arrive after a "catalogue of catastrophes''.
The inquest at Norfolk Coroner's Court heard an emergency first response car had been immediately dispatched from a mile away following the call at 11.09am on 11th March.
The family's solicitor read a statement outside the inquest:
The driver struggled to find the new-build house because the East of England Ambulance Trust's satellite navigation system was not up-to-date and "there were too many blue doors''.
An ambulance which was travelling on the nearby A11 was also diverted from another incident but this was low on fuel and had to stop for up to five minutes at a BP forecourt.
Controllers failed to tell the paramedics that an air ambulance had also been dispatched - if they had known they would not have needed to refuel.
Coroner William Armstrong recorded a narrative conclusion that the baby died from congenital heart disease after delays in medical assistance which reduced the prospects of her survival.
He said: "By anyone's standard this was a grave emergency - what happened here was a long, long way from the eight minute response target.
"We are told that at the time the ambulance service was experiencing significant demand and there were apparently insufficient resources to meet that demand.
"Twenty-six minutes in this situation is a very, very long period of time indeed.
"It is a fact that the prospect of a child surviving a cardiac arrest are low.
"Notwithstanding that the chance of resuscitation are improved if attempted immediately.
"The delay in giving Bella the care that she needed was wholly indefensible.
"There was a catalogue of catastrophes and a chaotic response.''
Bella, who had been born five weeks premature, was taken to the West Suffolk Hospital in Bury St Edmunds but later died from a heart defect, a condition she had been born with.
Her mother, Amy Carter, told the inquest: ``She was really cheeky and smiley. If you were having a bad day and you walked in to the room, all she had to do was smile and she would brighten the day up.''
Bella had been taken to hospital on two previous occasions and ambulances had previously been called to the house four times after she suffered health scares.
``Ambulances had never had any trouble finding our house before,'' Miss Carter, who attended the inquest with Bella's father Scott Hellings, told the hearing.
Consultant paediatrician Martina Noon said it was impossible to say whether Bella would have survived if she had arrived at hospital earlier but acknowledged her chances would have been improved.
Paramedic Sharon Jaggard, who was travelling in the ambulance, said that she and her colleague, Karen King, had not been told an air ambulance was also on its way.
Because of the mistake, they believed they would be required to take Bella to hospital rather than simply administer care at the scene.
She added: "If we had known the air ambulance had been sent, we would have got straight to the property.''
The air ambulance was later stood down.
Because of the problem with the trust's mapping system, crews were regularly forced to "zone'' to nearby areas and use local knowledge to find exact addresses.
The inquest heard that a review had been carried out in the ambulance service since the death.
Steps have been taken to ensure that sat navs are updated more promptly and staffing levels had been reviewed.
National guidelines state that an emergency response vehicle should reach 75% of patients deemed to be in a life-threatening condition within eight minutes.
After the inquest, the family issued a statement describing their ordeal.
They said: "We will always believe in ours hearts that Bella was let down by the health services when she was at her most vulnerable and when she needed help the most.''
Their solicitor added they are considering civil action against the trust.
John Martin, interim director of clinical quality at the East of England Ambulance Service NHS Trust, said: "I would like to express my condolences to the family.
"The trust's response to Bella was delayed for a number of factors, primarily the difficulty in locating the address due to it being a new build.
"As a result, a number of specific measures have now been put in place, and the trust has raised the problems of the delay in new buildings and developments appearing on maps and sat nav systems on a national level.
"In addition, the trust is recruiting more frontline staff and getting more ambulances on the road in order to improve our service for patients.''
He said the trust is also looking to make savings of up to #20 million in its support service areas "so that this money can be reinvested in frontline staff and ambulances''.