Bella Hellings inquest: Baby died after ambulance fuel stop
A baby girl died after an emergency response car got lost and an ambulance stopped for fuel, an inquest has heard.
Three-month-old Bella Hellings stopped breathing after she suffered a fit at her home in Thetford, Norfolk on 3 March. She died later in hospital.
Coroner William Armstong said paramedics had been delayed by a "catalogue of catastrophes".
He said the "wholly indefensible" delays reduced Bella's chances of survival.
The inquest in Norwich heard Bella's mother Amy Carter dialled 999 at 11.09 GMT.
An emergency first response car was immediately dispatched from a mile away, but the driver struggled to find the new-build house as the East of England Ambulance Trust's satellite navigation system was not up-to-date and "there were too many blue doors".
The inquest heard this problem had meant crews were regularly forced to use local knowledge to find exact addresses.
An ambulance travelling on the nearby A11 was also diverted to the house, but it was low on fuel and had to stop for up to five minutes at a BP forecourt.
The inquest heard paramedics took 26 minutes to arrive, more than three times longer than national targets dictate.
Controllers failed to tell them that an air ambulance had also been dispatched, meaning they would not have needed to refuel.
Paramedic Sharon Jaggard said that had they known about the helicopter, "we would have got straight to the property."
Bella, who was born five weeks premature, did not arrive at West Suffolk Hospital in Bury St Edmunds until 12:10, an hour after the 999 call was made.
Mr Armstrong recorded a narrative verdict, concluding that Bella died from congenital heart disease after delays in medical assistance which reduced the prospects of her survival.
"By anyone's standard this was a grave emergency - what happened here was a long, long way from the eight-minute response target," he said.
"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."
He said the delay was "wholly indefensible" and that there had been a "catalogue of catastrophes and a chaotic response."
After the inquest, Bella's family said they would "always believe in our 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 said they were considering civil action against the trust.
John Martin, interim director of clinical quality, said the service'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 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."
He added that the trust was also recruiting more frontline staff and getting more ambulances on the road.