Missed chances to save daughter found dead with mum
Nottingham Coroner's Court heard Alphonsine Djiako Leuga, 47, and 18-year-old Loraine Choulla had been dead for some time before they were found on 21 May 2024 in a house in Radford.
It was believed Alphonsine died first, in February, while Loraine - who had Down's syndrome and depended "entirely" on her mum - died of malnutrition and dehydration weeks later.
On Friday, assistant coroner Amanda Bewley said authorities "missed opportunities" to escalate concerns around the pair.
An inquest into their deaths, which started on Monday, heard Alphonsine had called for an ambulance on 2 February saying she was cold and could not move, but nobody attended.
Pathologist Dr Stuart Hamilton said he could "not rule out" that Alphonsine might have died on 2 February, which is when she called 999.
'Please come, please'
Alphonsine had been admitted to City Hospital on 26 January with a lower respiratory tract infection and needed blood transfusions due to low iron levels.
The inquest heard despite the hospital wanting her to stay, she was "discharged pragmatically" on 28 January to return to her daughter.
On 2 February, Alphonsine called 999 asking for an ambulance, the inquest heard.
She told a call handler she needed help for herself and her daughter.
"I feel cold and I can't move," she told the call handler.
In a transcript read out at the inquest, the call handler asked several times what language Alphonsine spoke and whether she needed an interpreter.
Despite not responding to those questions, she gave her address and asked again for an ambulance.
"Would you send an ambulance? Please come, please," were the last words she said on the phone before the call ended.
Keeley Sheldon, director of quality at East Midlands Ambulance Service, said the service "fully accept" the coroner's findings.
She said: "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.
"After our internal investigation, we made changes to our policies, procedures and training to ensure this does not happen in future."
If you have been affected by any of the issues raised in this story, support is available via the BBC Action Line
Follow BBC Nottingham on Facebook, on X, or on Instagram. Send your story ideas to eastmidsnews@bbc.co.uk or via WhatsApp on 0808 100 2210.
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