HOSPITAL and ambulance bosses have carried out two major investigations following the tragic death of a mother and her twins after suffering catastrophic heart failure, a coroner was told.

Chantelle Page, 28, collapsed in her flat at Topcliffe, near Thirsk, after twice calling for an ambulance. 

The Northern Echo:

A sign outside Friarage Hospital, Northallerton, North Yorkshire, where Chantelle Page, 28, who was pregnant with twins, was treated after she collapsed at home. Picture: PA

The first was diverted to a patient who had stopped breathing while a second crew sent from Harrogate – some 20 miles away – was unable to get in to her flat and waited 20 minutes for police to arrive and break the door down.

Paramedics carried out CPR and rushed Ms Page to the Friarage Hospital, Northallerton, where a team of doctors was waiting.

An emergency caesarean was performed but neither twin Violet Rose or Lilly Mae, around 27 weeks old at the time, or their mother could be saved.

North Yorkshire Coroner Michael Oakley said reviews carried out by Yorkshire Ambulance Trust and York Hospital, which had been treating Ms Page, found little to suggest she received anything other than proper care.

Pathologist Dr Mark Egan said she died as a result of a spontaneous catastrophic aneurysm in her heart. 

He told the Northallerton inquest: "It is an extremely uncommon cause of death which is acknowledged as a rare complication of pregnancy. Nobody would have been able to diagnose it.”

Ms Page, who had asthma and was a smoker, originally called for an ambulance at 10.49am on September 6, saying she was struggling for breath and had chest pains before calling again at 10.56am. 

The first ambulance was diverted to a higher priority call and another, sent from Harrogate, arrived at 11.28am.

Unable to get in, police were called to force entry at 11.50am. The air ambulance was also called.

Dr Stephen Sykes, of Yorkshire Ambulance Trust said an investigation was carried out into the delayed response and explained the initial ambulance was diverted to a patient who had stopped breathing. The second had to be sent from Harrogate due to high demand at the time.

He said they were now looking at ensuring they have the right number of staff deployed at the right time as well as protocols over access to properties. 

Mr Oakley said: "It is a judgement of Solomon, by the time the ambulance did attend it seems to have been extremely efficient.”

Consultant Nicola Dean from York Hospital said a serious incident report into Ms Page’s death concluded there had been no lapses in professional care. 

Her family asked if she should not have been getting increased consultant care, she replied this was provided through the consultant led team.

"Taking into account the high mortality rate of this event and the risk factors of this patient as well, the time delay, I don’t think it would have changed the outcome.”

Ms Page’s partner Mark Bramhald said in a statement he spoke to her at 10.45am that morning and she said she was fine.

Mr Oakley recorded verdicts of natural causes on Chantelle and Violet Rose and stillbirth on Lilly Mae. 

He added. “These were very distressing occurrences for the family and also for the medical staff who treated them. There weren’t any big lessons to be learned from this, it was one of those very tragic occurrences.”