Lauren Braisby desperately tried to save her tiny son Jenson with CPR as she waited on the phone for more than four minutes.
But despite the best efforts of his 17-year-old mum and some paramedics they met on the way, Jenson was pronounced dead within minutes of arriving at Eastbourne District General Hospital.
An inquest into Jenson’s death was held at Eastbourne Town Hall this morning.
Jenson and his twin brother Alfie were born premature in July 2017 and had to spend time recovering in a specialist neonatal unit.
Both had been discharged and were living with their mum in Highgrove Crescent in Polegate when tragedy struck in the early hours of July 25.
Coroner’s officer Karen Brown said: “Lauren called 999 after finding Jenson unresponsive just after 4am.
“Lauren told them that her baby needed an ambulance as he was not breathing.
“The call lasted four minutes and three seconds and was not answered by the ambulance service.”
When the ambulance service continued not to answer, Lauren put her seven-week old son in the car and set off for the hospital, the inquest heard.
She managed to flag down an ambulance on route and paramedics battled to save Jenson’s life.
However he was confirmed dead just minutes after arriving at Eastbourne District General Hospital.
Speaking at the inquest, consultant paramedic James Bradfield was asked why Lauren’s call was never picked up.
According to South East Coast Ambulance Service (SECAmb) policy at the time, Jenson would have been a ‘RED1’ incident, meaning paramedics should have been at his door within eight minutes.
Mr Bradfield said: “There were insufficient members of staff on duty in the main operations centre at the time of the call, which was the root cause of the result the 999 call was not answered.
“The 999 operator did not get a response from our control room because at the time there were not enough advisors able to take that call.”
The coroner was told the reason for the low staff numbers was sickness.
However SECAmb staff told the inquest that improvements have been made to ensure such a tragedy never happens again.
A post-mortem examination ‘failed to ascertain’ any factors which could have contributed or caused Jenson Braisby’s death, the inquest heard.
Pathologist Simi George categorised the case as a sudden unexplained death of an infant.
Senior coroner Alan Craze said: “It is a failure by the ambulance service to pick up the phone at all.
“There was no one to take that call.”
However he added: “We are dealing with human beings, hardworking human beings in the middle of the night, and we can’t expect to get it right every time. That is a fact of life.”
He gave a conclusion of an unexplained sudden infant death from natural causes.
He added: “One of the sad things for me has it is not been possible to engage the parents of this boy in the inquest process because the other twin is extremely ill and it is taking up all of the mother’s time.”
Mr Craze asked that his condolences be passed on to Jenson’s family.
Following the inquest, a spokesman for the South East Coast Ambulance Service (SECAmb) said: “Our thoughts are with the family at this difficult time and we are very sorry for the service they received in such tragic circumstances.
“We have worked with the coroner and attended today’s inquest to give evidence.
“We also carried out our own thorough investigation and have made significant improvements to our call answer performance thanks, in part, to improved recruitment and retention of staff in our Emergency Operations Centres.”