Charlotte Burston died on New Year's Eve six days after suffering a heart attack on Christmas Day which led to a cardiac arrest.
The Welsh Ambulance Service missed opportunities to send a quicker vehicle which could have saved a woman's life after she suffered a fatal heart attack on Christmas Day in 2023, an inquest has heard. Charlotte Burston, 40, was told an ambulance would take an hour and a half when her daughter told them she was suffering with chest pain.
Instead of waiting for the paramedics to arrive, her step-father drove her to hospital but on the way she suffered a cardiac arrest. On December 31 she died having suffered a hypoxic brain injury as a result of the cardiac arrest.
In a statement read out from Charlotte's mum, Helen Lay, the inquest heard how Ms Burston grew up in Surrey and Hampshire, before she qualified as a beautician. She later moved to Pembrokeshire where she lived with her two daughters in Narbeth. Don't miss a court report by signing up to our crime newsletter here
The court heard how she had no major health issues but had seen the doctor for symptoms of stress, anxiety, and depression. Her mum said how during the week before Christmas, "her anxiety was through the roof".
Mrs Lay explained how between eight and half eight on the morning of December 25 she received a call from her granddaughter asking her to come around because her mum wasn't well. After calling her grandmother, she phoned 999 where she was told by the call handler that an ambulance would take one and a half hours.
Mrs Lay and her husband arrived shortly after, and while having called 999 back, Mr Lay decided he would take Charlotte to Withybush Hospital. Ms Burston lost consciousness on the way and suffered a cardiac arrest. She was later transferred to Morriston Hospital but never regained consciousness and died on New Years Eve.
In a statement read by her mum, she was described by her friends as being bubbly, caring, strong, kind, empathetic, and considerate.
Andrew Garner, service manager for operations quality at the Welsh Ambulance Service, told Pembrokeshire Coroner's Court how Ms Burston's daughter's call had generated an amber one response which he said was for life-threatening conditions which don't require a response within seconds.
Mr Garner told the inquest that an APP, an Advanced Paramedic Practitioner, was identified as being 29 minutes away in Haverfordwest. He explained that such vehicles cannot convey patients to hospital but have all the equipment and drugs necessary.
However, a decision was made not to allocate the APP and instead an emergency ambulance which had an ETA of 45 minutes from Cardigan paramedic station was dispatched. The ambulance was later cancelled after Mrs Lay told the call handler her husband was taking her daughter to hospital.
Mr Garner told the inquest that an internal investigation by the Welsh Ambulance Service identified missed opportunities in how the call was managed. He said: "The internal investigation concluded that the APP should have been allocated to Charlotte, that would have meant it would have arrived around nine o'clock which was before she was taken to hospital so she would've been home."
He also explained that her call would've been managed "very differently" now to how it was in 2023.
Mr Garner added: "We should have got to Charlotte within half an hour and we should have been with her when she had the cardiac arrest."
Ms Burston, of Mountain View, Llanteg, Narbeth, had a cause of death of hypoxic brain injury, cardiac arrest, and myocardial infarction.
John Heyworth, a completely independent medical expert who works as a consultant in emergency medicine, said she had suffered a myocardial infarction, more commonly referred to as a heart attack, which can in some cases cause a cardiac arrest where the heart stops pumping.
He said she had an abnormality in her left anterior descending artery which was something that could occur in young, healthy individuals with no prior warning. He said: "This tragedy strikes out of the blue."
When asked whether, on the balance of probabilities, sending an APP would have led to Ms Burston surviving, Mr Heyworth said that a defibrillator should mean survival and Ms Burston would have received this from the APP.
Coroner Mark Layton ruled a narrative conclusion. He added: "Charlotte died at Morriston Hospital on December 31, 2023, from a hypoxic brain injury having suffered a myocardial infarction on December 25 leading to a cardiac arrest. Emergency calls did not result in the dispatch of an APP which on the balance of probabilities could have provided lifesaving treatment."