A 999 call handler has admitted she made two “fundamental” errors in responding to a report of a choking baby who later died, an inquest has heard.
Staff at Ramillies Hall private nursery in Cheadle Hulme, Manchester, rang for assistance after nine-month-old Millie Thompson got into breathing difficulties after she was fed shepherd's pie.
An inquest into her death heard that North West Ambulance Service employee, Aaliyah Ormerod, made mistakes in how she graded the call last October.
Ms Ormerod admitted she did not appreciate the seriousness of the situation and did not stay on the line to monitor Millie’s condition.
In a statement read to the court, Ms Ormerod said she began to ask a series of scripted questions when she received the call.
Staff told her the baby was choking, crying, still breathing but was going "a bit purple" and gave her the address of the scene.
But Ms Ormerod continued to ask further scripted questions and learned the child was not breathing normally after she had choked.
Ms Ormerod ended the call by asking the school to ring back immediately if anything changed.
Nursery staff performed first aid on the youngster as they waited for emergency assistance on October 23.
An ambulance arrived 10 minutes later but Millie had gone into cardiac arrest and less than an hour later she was pronounced dead at Stepping Hill Hospital.
Following a review of the call, Ms Ormerod admitted she had made the "fundamental errors".
She stated: "When told the patient was going purple, I did not click this indicated breathing problems."
This should have generated a more immediate response and not a continuation of the scripts she followed, she said.
She went on: "I should have stayed on the line to monitor the patient's breathing and not exit the call."
Explaining that she had suffered a stillbirth herself, she said the thought that her actions could have contributed to a death "has devastated me".
She added she considered it an "isolated error" and said she thought the automatic prompting system should be improved.
Ms Ormerod returned to work about six months ago in the same role, although a doctor ruled her medically unfit to give evidence this week at the inquest or in the foreseeable future.
Addressing the jury on the opening day of the inquest yesterday, Millie’s mother Joanne said all she wanted to know was how her "perfectly healthy" daughter did not come home from the nursery.
A recording of the 999 phone call was played to the jury.
At the end of the call, when the operator says goodbye, she is still being recorded as she says: "Jeez, stop giving me information."
South Manchester coroner John Pollard said he expected her employers to take action over that comment.
Angela Lee, section manager in the emergency control room, said the call operator should have graded a "red response" of an immediate threat to life.
That requires a vehicle response within eight minutes, the inquest heard.
Asked why Ms Ormerod had not chosen that option, Ms Lee said: "The call operator did not follow her training and did not identify Millie had ineffective breathing at the start of the call.
"The word 'purple' or 'blue' or 'gasping for breath' acts as a trigger for an immediate red response before any more questions are asked."
She explained that made no practical difference in this case as to how quickly the ambulance arrived but a rapid response car might have got there one or two minutes sooner.
Ms Lee said the operator did not have an explanation as to why she did not stay on the line but said she felt she had been "bombarded with details".
Mr Pollard said: "What I cannot understand is there can only be in my mind no more important a call than a baby choking?"
The witness said: "I totally agree with you. She should have stayed on the line. It's unacceptable."
The coroner suggested: "This was a complete aberration."
Ms Lee replied: "Yes."
The inquest heard that so far no disciplinary proceedings have been taken against the call operator.
The hearing continues next Tuesday.
Additional reporting by Press Association.