Overview

• The coroner recorded that Alphonsine Leuga died of pneumonia of uncertain origin and that her daughter, Loraine Choulla, died from dehydration and malnutrition linked to her disabilities.
• East Midlands Ambulance Service formally apologised for closing the February 2 call as abandoned and has updated its abandoned-call protocols, staff training and dispatch procedures.
• Nottingham City Council Social Care made nine welfare visits between February and mid-May 2024 but failed to escalate concerns, and it is now conducting a full review of its safeguarding practices.
• Pathologist Dr Stuart Hamilton testified that both bodies showed significant decomposition, indicating they likely died weeks to months before their discovery on May 21, 2024.
• The case has exposed critical gaps in emergency response classification and social service oversight for isolated, disabled individuals living at home.