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'Missed opportunities' to save disabled girl found dead with mum 'Missed opportunities' to save disabled girl found dead with mum
(32 minutes later)
Alphonsine Djiako Leuga, right, and Loraine Choulla were found dead in their home in May 2024Alphonsine Djiako Leuga, right, and Loraine Choulla were found dead in their home in May 2024
A disabled teenage girl could have been saved if an ambulance had attended her dying mother's 999 call - months before they were both found dead in their home, a coroner has concluded.A disabled teenage girl could have been saved if an ambulance had attended her dying mother's 999 call - months before they were both found dead in their home, a coroner has concluded.
Nottingham Coroner's Court heard Alphonsine Djiako Leuga, 47, and 18-year-old Loraine Choulla had been dead for some time before they were found on 21 May 2024 in a house in Radford. Nottingham Coroner's Court heard Alphonsine Djiako Leuga, 47, and 18-year-old Loraine Choulla had been dead for some time before they were found on 21 May 2024 in a house in Hartley Road, Radford.
It was believed Alphonsine died first, in February, while Loraine - who had Down's syndrome and depended "entirely" on her mum - died of malnutrition and dehydration weeks later.It was believed Alphonsine died first, in February, while Loraine - who had Down's syndrome and depended "entirely" on her mum - died of malnutrition and dehydration weeks later.
On Friday, assistant coroner Amanda Bewley said authorities "missed opportunities" to escalate concerns around the pair.On Friday, assistant coroner Amanda Bewley said authorities "missed opportunities" to escalate concerns around the pair.
An inquest into their deaths, which started on Monday, heard Alphonsine had called for an ambulance on 2 February saying she was cold and could not move, but nobody attended. The inquest, which started on Monday, heard Alphonsine had stopped engaging with local services - including social care, medical care and education services - but a reason for this was never identified.
Pathologist Dr Stuart Hamilton said he could "not rule out" that Alphonsine might have died on 2 February, which is when she called 999. On 2 February 2024, Alphonsine called for an ambulance saying she was cold and could not move, but nobody attended.
Pathologist Dr Stuart Hamilton said he could "not rule out" that Alphonsine might have died on that day.
'Please come, please''Please come, please'
Alphonsine had been admitted to City Hospital on 26 January with a lower respiratory tract infection and needed blood transfusions due to low iron levels. Alphonsine had been admitted to hospital days earlier with a lower respiratory tract infection and needed blood transfusions due to low iron levels.
The inquest heard despite the hospital wanting her to stay, she was "discharged pragmatically" on 28 January to return to her daughter.The inquest heard despite the hospital wanting her to stay, she was "discharged pragmatically" on 28 January to return to her daughter.
It was agreed she would return the next day, but she did not come back, and the hospital and her GP were unable to contact her. In the 2 February 999 call, Alphonsine told the handler she needed help for herself and her daughter.
On 2 February, Alphonsine called 999 asking for an ambulance, the inquest heard.
The pair were found dead in their council house in Hartley Road
She told a call handler she needed help for herself and her daughter.
"I feel cold and I can't move," she told the call handler.
In a transcript read out at the inquest, the call handler asked several times what language Alphonsine spoke and whether she needed an interpreter.
Despite not responding to those questions, she gave her address and asked again for an ambulance.
"Would you send an ambulance? Please come, please," were the last words she said on the phone before the call ended."Would you send an ambulance? Please come, please," were the last words she said on the phone before the call ended.
The coroner added: "I'm entirely satisfied had an ambulance been sent to Alphonsine, then Loraine would not have died when she did.
"She would most probably have still been alive today."
Ms Bewley added there "missed opportunities, particularly by Nottingham City Council social care teams, to escalate concerns" around the pair and to involve police in welfare checks.
The pair were found dead in their council house in Hartley Road
Keeley Sheldon, director of quality at East Midlands Ambulance Service, said the service "fully accept" the coroner's findings.
She said: "I am truly sorry that we did not respond as we should have to Alphonsine Djiako Leuga and Lorraine Choulla. Our deepest condolences remain with their family.
"After our internal investigation, we made changes to our policies, procedures and training to ensure this does not happen in future."
In a statement, a Nottingham City Council spokesperson said: "We take our responsibilities seriously and have already undertaken a review of relevant policies, procedures and practices to ensure any necessary improvements are made, and that learning is embedded across our services.
"We are committed to acting decisively and continuing to work closely with our partners to safeguard the wellbeing of all Nottingham's citizens.
"We would like to extend our sincere condolences to the Leuga and Choulla families. Our thoughts are with them at this extremely difficult time."
If you have been affected by any of the issues raised in this story, support is available via the BBC Action Line
Follow BBC Nottingham on Facebook, on X, or on Instagram. Send your story ideas to eastmidsnews@bbc.co.uk or via WhatsApp on 0808 100 2210.Follow BBC Nottingham on Facebook, on X, or on Instagram. Send your story ideas to eastmidsnews@bbc.co.uk or via WhatsApp on 0808 100 2210.