A YOUNG woman died after waiting an hour and 25 minutes for an ambulance because of a catalogue of failings at an under-pressure 999 control room.

At one stage as Kathryn Richmond, 20, lay struggling for breath, six of the 13 ambulances for East Dorset were off the road for meal breaks.

When the university student eventually reached hospital, she went into cardiac arrest. Although she was revived and underwent emergency surgery, she arrested a second time and died.

A surgeon said that had Kathryn, from Broadstone, been treated earlier, she would probably have survived.

An inquest heard evidence of control room staff at South Western Ambulance’s St Leonards hub being pressurised into thinking twice about putting through too many life-threatening 'red' cases. A lack of ambulances meant they struggled to meet response targets.

The coroner will write to health secretary Jeremy Hunt recommending rotas and meal breaks across the UK be staggered.

Kathryn suffered a ruptured spleen due to a very rare complication from glandular fever and collapsed at home just after midnight on April 21, 2015.

Her parents, Alan and Jacqueline, called 999 at 12.14am and Kathryn was listed as life-threatening Red 2 - meaning an ambulance should have reached her within eight minutes.

One was dispatched at 12.15am, but call handler Tanya Javadi wrongly downgraded it and her ambulance was sent to another emergency.

Her parents called again at 12.40am and Kathryn was re-listed as a Red 2 case. All ambulance crews in the vicinity were on a break so one 25 minutes away was sent.

But it was called off after clinical supervisor Duncan Smith downgraded the call again.

The hearing heard Mr Smith ‘fixated’ on an assumed diagnosis that asthmatic Kathryn was hyperventilating, when further probing would have revealed she was in hypovolemic shock.

At 1.31am, when the control room called back to check on Kathryn, six ambulances in the area were off the road because of meal breaks.

Paramedics finally arrived at 1.39am and realised Kathryn needed immediate hospital care. She died at 6.22am.

Paul Durdey, a consultant general surgeon, said: "Any surgical or medical intervention that could prevent cardiac arrest probably would have led to the operation being successful and Kathryn surviving."

Asked by coroner Rachael Griffin if he felt under pressure to downgrade Kathryn's call, Mr Smith said: "Yes, there is some pressure, more so in the Dorset hub because the dispatchers would be sat 2ft in front of me, looking at me, asking if that call is going to be red.”

But he added: "I did feel under pressure but that did not impact upon my clinical decisions."

Addressing Kathryn's parents, Mr Smith said he should have probed further on the ‘shock question’.

“When I discovered what had happened, I knew that's where I should have picked it up in the call,” he said.

"I wish that call's final distinction was red so much."

Nicholas McGuinness, senior dispatcher on the night, said: "We used to have ambulances waiting for calls, now we have a stack of calls that are waiting for ambulances.

"The amount of resources we are provided with is far lower than we need to safely deal with the amount of calls we receive in this area."

Dr Andy Smith, medical director for the ambulance trust, said it had made a number of improvements.

Mrs Griffin recorded a narrative verdict, saying Kathryn died of natural causes but the delay had been “contributory”.

"The delay was due to individuals' judgements, assessments and mistakes. Those are not system failures,” she said.

"There are a number of issues which give me concerns but considerable effort has been made to address those."

After the inquest, Mrs Richmond said: "It's heartbreaking to have heard that Kathryn would not have died but for that delay. We are devastated by the loss of our lovely daughter.

"We hope that the proposed changes we have heard about mean this will never happen again.

"We would like to thank the Poole hospital team that tried so desperately to save Kathryn's life on that night."

A spokesman for the ambulance trust offered "sincere condolences", adding: "We are very sorry that we did not arrive to treat Kathryn in time.

"We have since made significant changes to our systems to minimise the risk of this happening again."