A mother and her daughter were discovered dead inside their Nottinghamshire, England home, victims of what an inquest described as ‘missed opportunities,’ with their bodies found four months after an emergency call was made.
Alphonsine Djiako Leuga, 47, and her daughter, Loraine Choulla, 18, were found in May 2024. An inquest revealed crucial moments that could have potentially saved their lives.
During the inquest, representatives from Nottingham Police, Nottinghamshire Coroner’s Service, and East Midlands Ambulance Service appeared in court. It was disclosed that Alphonsine had dialed 999 for an ambulance, which ultimately never arrived.
The emergency call was terminated shortly after Alphonsine’s plea for help, and although the dispatcher attempted to re-establish contact, these attempts failed and the call was mistakenly categorized as ‘abandoned’.
“Would you send an ambulance? Please come, please,” were Alphonsine’s final words before the call cut off.
Detective Con Jack Cook from Nottinghamshire Police suggested that Alphonsine might have died shortly after placing the call.
Alphonsine was suffering from a lower respiratory tract infection in the weeks before her death and also had sickle cell anemia, which contributed to her feeling cold and immobile during her call for help.
Loraine, who had Down’s syndrome and learning difficulties, was described as ‘entirely dependent’ on her mother.
It is believed Loraine passed away on or after February 28, as this was the last recorded activity on her Samsung tablet.
The coroner concluded that while Alphonsine likely died from ‘pneumonia of uncertain cause,’ Loraine’s death resulted from malnutrition and dehydration.
Loraine is thought to have died before reaching her 18th birthday, which would have been in April.
Amanda Bewley, the Assistant Coroner, stated that authorities had ‘missed opportunities’ to escalate the situation concerning the mother and daughter.
The coroner further commented, “I’m entirely satisfied had an ambulance been sent to Alphonsine, then Loraine would not have died when she did.
“She would most probably have still been alive today.”
Bewley highlighted the missed opportunities, particularly by Nottingham City Council social care teams, to escalate concerns and involve the police for welfare checks.
It was revealed that in 2023, Cook had visited the family’s home to assist social services, according to the BBC.
He noted that there was an adequate amount of food in the refrigerator and that the house was well-kept.
However, when the bodies were discovered in May, there was evidence of decaying food and signs suggesting Loraine had constructed a ‘den’ between two beds, living alone in the home while her mother’s body lay undiscovered.
The discovery of the bodies was made by a passer-by, rather than one of the services, highlighting another missed opportunity.
Bewley expressed her astonishment that it was a passer-by who took the initiative to contact the police, rather than ‘one of the professionals’ involved in their care.
Following the inquest, East Midlands Ambulance Service issued a statement: “I am truly sorry that we did not respond as we should have to Alphonsine Djiako Leuga and Lorraine Choulla. Our deepest condolences remain with their family,” stated Keeley Sheldon, Director of Quality at the organization. “We fully accept the Coroner’s findings. After our internal investigation, we made changes to our policies, procedures, and training to ensure this does not happen in future.”