Overview
- A paramedic told the court the multi‑agency response felt disjointed, with weak communication on scene and no clear incident lead under standard joint working rules.
- Evidence from the 999 transcript showed the call at 7:52pm was first handled as an entrapment, which led to advice not to attempt a rescue before drowning‑specific questions began at 7:59pm.
- The coroner heard firefighters were contacted after about 12 minutes and dispatched several minutes after first inter‑service contact, arriving at 8:22pm and freeing her at 8:32pm, as an ambulance leader said fire crews should have been alerted within seconds.
- Witnesses, including the victim’s child, tried to pull her from the sea‑defence boulders but she became unresponsive as the tide rose, and rescuers later found her unresponsive.
- Post‑mortem toxicology recorded 271 mg of alcohol per 100ml of blood, and the hearing is now testing whether call‑handling software, training gaps, and on‑scene coordination changes could prevent similar deaths.