Overview

• A 999 call on February 2, 2024, from Alphonsine Djiako Leuga was misclassified as abandoned after she gave her Radford address, so no ambulance was dispatched to her home.
• East Midlands Ambulance Service’s head of patient safety, Susan Jevons, acknowledged a ‘missed opportunity’ and has reinforced abandoned-call procedures, with no similar errors since February 2024.
• Pathologist Dr Stuart Hamilton testified that both women were likely dead for “weeks to months,” that Alphonsine died of pneumonia and that Loraine Choulla’s cause of death remains officially unascertained.
• Evidence showed Ms Leuga repeatedly refused social workers, council officers and community nurses and withdrew her daughter from school, limiting outside intervention before their deaths.
• Coroner Amanda Bewley is examining whether an earlier ambulance dispatch could have saved Loraine, with final determinations on EMS failures and cause-of-death certifications due at the inquest’s conclusion Friday.