On 21/08/2014 commenced an investigation into the death of Jasmine Ruby Lapsley investigation concluded at the end of the inquest on 12 January 2016. The conclusion of the inquest was that Jasmine's death was due to an accident medical cause of death was 1a. Choking

On 19 August 2014 6 year old Jasmine Lapsley was on holiday with her family at a property in Morfa Nefyn on the Lleyn Peninsula in the County of Gwynedd. At 20.30 hours Jasmine choked on a grape. Her father tried to dislodge the obstruction immedi-ately by backslaps and the Heimlich Manoeuvre Jasmine stopped breathing and was un-responsive_ At 20.31 hours Jasmine's grandmother ran 999 and spoke to Ambulance Control at 20.32 The call was registered at 20.34 hours The call was correctly classified as RED 1, the most serious requiring attendance without delay: The response time for Welsh Ambulance NHS Trust arriving at RED patients is to arrive at 65% of patients with-in 8 minutes The nearest two ambulances at Pwllheli, some miles away were not available_ The next nearest available ambulance was dispatched at 20.33 This was at Porthmadog 20 miles and some 24 minutes from Morfa Nefyn: The roads between Morfa Nefyn and Porthmadog are winding; narrow and down to one lane in many places_ Ambulance trol contacted Community First Responders in Morfa Nefyn but all calls went to voicemail. At 20.35 two Community First Responders contacted Ambulance Control to confirm that they could attend and were mobilising: were some 7.5 miles and 19 minutes away: Community First Responders are unpaid volunteers trained by Welsh Ambulance NHS Trust (WAST): are trained in basic first aid and are equipped with defibrillators and other essential equipment to maintain an airway and perform CPR and keep a patient alive until an ambulance or other WAST resource arrives. Community First Responders are a valuable resource in rural and remote areas_ Under current arrangements when they are available inform Ambulance Control. There is no formal rota system ensuring contin-uous cover in all areas The method for contacting CFRs is generally by mobile telephone which is not a reliable form of communication in rural and remote areas due to the patchy 37 Castle Square, Caernarfon, Gwynedd, LLSS 2NN Tel 01286 672804 Fax 01286 675217 The The Con-They They they availability of networks During the Inquest the Manager of Ambulance Control gave evidence that had the 999 call been received at 6 pm then the Air Ambulance would have been dispatched immediately given the gravity of the situation. Wales Air Ambulance is a charity which exists solely as a resource for WAST. It is classed as a WAST resource: It is clear that the incident involving Jasmine required the immediate dispatch of Air Support Wales Air Ambulance only flies between am and pm. There was no WAST resource Air Support available for Jasmine It is the practice of Ambulance Control to go through all WAST resources to ascertain whether they can assist before contacting alternative support This was the reason given by WAST for not contacting the RAF 22 Squadron Search and Rescue helicopter until 20.46, 13 minutes after the original 999 call: were already airborne and proceeded straight to Morfa Nefyn: Whilst the 999 call was in progress a neighbouring off duty police man attended and com-menced CPR, shortly followed by his wife an employee of WAST and a first aid trainer. relentlessly carried out appropriate CPR in an attempt to resuscitate Jasmine_ Some air was entering her lungs as evidenced by the rise and fall of her chest It is likely by this stage that the grape was no longer fully occluding the airway and was dislodged to some extent by back slaps. At 20.45 a local fire crew were flagged down by a family member and assisted briefly in CPR before the neighbours took over once more. This CPR continued until the ambulance arrived: The Community First Responders attended at 20.54 hours. The ambulance was logged by Ambulance Control as being 200 metres away at 20.57 . The RAF aircraft arrived within minutes of the ambulance. Jasmine was transferred from the ambulance to the aircraft and airlifted to Ysbyty Gwynedd; Bangor: She arrived in the Emergency Department at 21.33. Despite of the best efforts of the clinicians at the Emergency Department to resuscitate Jasmine the decision was made to withdraw treatment and Jasmine sadly died at 23.58 hours. RAF 22 squadron Search and Rescue helicopter were often called to assist WAST when WAST were unable to attend to retrieve andlor treat patients_ Unless involved already in their primary duty of Search and Rescue the RAF always assisted WAST. The duties of RAF Search and Rescue in North West Wales were transferred to a private company Bris-tows in 2015. Bristows continue to assist WAST as the RAF did previously: WAST had no Protocol; Memorandum of Understanding or Standard Operating Procedure to formalise or govern the relationship between WAST and RAF The position remains the same with Bris-tows. This is not a reliable resource for WAST as is only available when not engaged on their primary duty of search and rescue. There is no obligation upon them to assist in any event 37 Castle Square, Caernarfon, Gwynedd, LLSS 2NN Tel 01286 672804 01286 675217 They They Fax