Alphonsine Djiako Leuga, 47, and daughter, Loraine Choulla, 18, were found deceased at their Nottinghamshire, England home in May 2024, and an inquest has found startling moments that could have saved the pair.

The inquest, which saw the Nottingham Police, the Nottinghamshire Coroner’s Service and the East Midlands Ambulance Service appear in court, revealed that Alphonsine had called 999 for an ambulance that never came.

The reason for this was that the call ended shortly after her plea, and while the dispatcher made attempts to contact her – attempts that were unsuccessful – it was incorrectly labeled as an ‘abandoned call’.

“Would you send an ambulance? Please come, please,” were the last words she said before the call ended.

Detective Con Jack Cook of the Nottinghamshire Police claimed that Alphonsine may have died soon after making her call.

Mom Alphonsine Djiako Leuga and her daughter, Loraine Choulla (Family Handout)

The mother, who had been treated for a lower respiratory tract infection in the weeks leading up to her death, also had sickle cell anaemia, which led to her feeling cold and unable to move during her desperate call.

Her daughter, Loraine, had Down’s syndrome and learning difficulties, making her ‘entirely dependent’ on her mom.

Sadly, it is believed that Loraine died on or after February 28, when activity on her Samsung tablet was last recorded.

While the coroner believes Alphonsine died of ‘pneumonia of uncertain cause’, Lorraine’s cause of death was malnutrition and dehydration.

Sadly, it is believed that Loraine died before her 18th birthday, which she would have celebrated in April.

Assistant coroner Amanda Bewley said authorities ‘missed opportunities’ to escalate concerns around the mother and daughter.

The coroner added: “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 added that there had been ‘missed opportunities, particularly by Nottingham City Council social care teams, to escalate concerns’ and to involve police in welfare checks.

An explanation for what happened was given during an inquiry this week (Jacob King/PA Images via Getty )

However, it had been revealed that Cook had visited the family’s home in 2023, to support social services, the BBC reports.

He reported there was plenty of food in the refrigerator and the house was clean.

But when the pair were found dead in May, there was moldy and half-eaten food and evidence to suggest Loraine had made a ‘den’ in between two beds as she lived on her own in the home where her mother’s body lay for weeks.

There was also a missed opportunity for one of the services to have discovered the bodies, instead of a passer-by alerting police to the deceased pair.

Bewley said it was ‘astonishing to [her] that it was that person who took the initiative to call the police’, and not ‘one of the professionals’ involved in their care.

East Midlands Ambulance Service said in a statement following the inquest: “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,” Keeley Sheldon, Director of Quality at the organization, said in the statement. “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.”

Alphonsine Djiako Leuga, 47, and her daughter, Loraine Choulla, 18, were found deceased at their Nottinghamshire home in May last year.

Most tragically, an inquiry revealed that the mother had called 999 to get an ambulance that never came.

Officials from Nottingham Police, the Nottinghamshire Coroner’s Service and the East Midlands Ambulance Service have spoken out in court about this incident and revealed their findings following an inquiry this week.

The inquiry began on July 21, and at the inquest, Detective Con Jack Cook of the Nottinghamshire Police explained that authorities now believe that Alphonsine died not long after making the call to the emergency services.

Investigations showed Loraine, who had Down’s syndrome and learning difficulties and was ‘entirely dependent’ on her mother, had been alive until 28 February.

Mom Alphonsine Djiako Leuga called the emergency services, but an ambulance never arrived, leading to the death of herself and her daughter, Loraine (Family Handout)

Alphonsine’s call was answered on February 2, and the mother was able to give her address and ask them to send an ambulance before the call ended.

However, the call had incorrectly been labelled as an ‘abandoned call’

Detective Cook said: “Loraine had been left in the premises alone and had been alive until her device had lost charge.”

Authorities believe that Lorraine died before her 18th birthday in April.

Alphonsine had health issues herself and suffered from sickle cell anaemia. She died of ‘pneumonia of uncertain cause’; however, her youngest daughter’s cause of death remains ‘unascertained’.

During the hearing, pathologist Dr Stuart Hamilton was asked if the child’s death may have been because of dehydration or malnutrition. He responded: “There is nothing in my findings that say any of that is incorrect.”

An explanation for what happened was given during an inquiry this week (Jacob King/PA Images via Getty)

Regarding the ambulance not being dispatched to the home, the head of patient safety at the East Midlands Ambulance Service, Susan Jevons, spoke on the matter during the inquest.

She claimed the telephone dispatcher in question had tried repeatedly to contact Alphonsine after the call abruptly ended.

She said: “The ambulance didn’t go to the address because the emergency medical adviser, thinking it was an abandoned call, closed the call down.”

Jevons went on to apologize for ‘all of the errors’ made by the service.

She added that the team’s failure to dispatch an ambulance should ‘never have happened’.