Trapped upside down in a gap between sea defence boulders, mother-of-six Saffron Cole-Nottage drowned in front of her daughter as the tide rose over her head.

Ever since her death at Lowestoft on February 2, 2025, questions have been raised about whether the emergency services could – or should – have done more to save the 32-year-old’s life. For the last two weeks an inquest in Ipswich has forensically examined the role played by the ambulance service, the coastguard, police and firemen.

Here, Tom Rawstorne outlines the extraordinary minute-by-minute course of events that saw a young mother lose her life in the most tragic of circumstances.

Lunchtime

Saffron went to the Hatfield Hotel, Lowestoft, with her father and stepmother, Patricia Cole, for Sunday lunch. According to Ms Cole, Saffron drank three pints of Foster’s lager with the meal. Afterwards, the inquest heard, she visited another pub.

A post-mortem examination found that Saffron had 271mg of alcohol in 100ml of blood, which pathologist Raj Logasundarum said would ‘have significantly impaired her cognitive abilities’. The drink-drive limit is 80mg.

7pm

Saffron spent around 30 minutes dancing with her children in the kitchen.

In a pen portrait read to the inquest, Saffron’s family said the devoted mother was ‘bubbly, fun and full of life’.

7.30pm

Saffron headed out for a walk with her daughter and dog Blue. About five minutes from her home, she lost her footing on a slippery flat concrete ‘apron’ between the sea defence boulders and the promenade.

Due to a recent full moon, that evening the tide was coming in unusually fast, and was 80cm higher than normal.

7.45pm

Saffron’s daughter desperately screamed for help. Her mother had fallen headfirst among the sea defence boulders and was unable to free herself.

The girl attempted to pull her free by her legs, yanking off her trainers as she did so.

Alerted by her cries, passer-by Alex Singleton-Dent ran from the seafront. Using his phone light to illuminate the scene, all he could see was ‘two legs sticking out’.

Silent at first, Saffron started to panic and scream, shouting for help. ‘We worked to try and get her out but we just couldn’t,’ said Mr Singleton-Dent.

Another girl who was with two friends, none of whom can be named for legal reasons, also tried to assist. ‘We spent around 15 minutes trying,’ she said. Meanwhile, her young friend dialled 999.

7.52pm

The 999 call from the girl was put through to the East of England Ambulance Service and dealt with by NHS emergency call handler Daniel Joy.

The girl was on the line for 19 minutes in total as Mr Joy worked through a series of computer-generated prompts trying to ascertain what had happened and how to proceed.

Mr Joy: ‘Is the patient breathing?

Caller: ‘Yeah, she’s shouting “help”.’

Mr Joy: ‘Patient awake?’

Caller: ‘Yeah she fell down headfirst in the rocks at the seafront.’

Mr Joy: ‘Is she in the water?’

Caller: ‘I don’t know because I can’t see very well.’

7.55pm

The call continued.

Mr Joy: ‘Is she in the water or is she just by the rocks?’

Caller: ‘I know she’s wedged between two rocks…’

Mr Joy: ‘Trapped between two rocks...okay.’

Caller: ‘A few rocks…I think two…yeah.’

Mr Joy: ‘Yeah, okay. I’m just making a note of that…’

7.56pm

The hearing heard it took four minutes to accurately get the location of the incident.

By then, Mr Joy had categorised the call at as being an ‘entrapment’, leading to an ‘entrapment protocol’ being enacted.

As the caller informed him that Saffron was ‘really screaming and everything’, Mr Joy told her to ‘bear with me one moment’ while he spoke with a senior colleague.

But Christopher Strutt, the call handler team leader, told the inquest that the way Mr Joy ‘escalated the information’ to him ‘didn’t give me a true sense of urgency’.

He said: ‘I very clearly remember Dan saying to me, “I have a patient who has fallen on the seafront”.’

Mr Strutt admitted that the fire service should have been contacted by the ambulance service within seconds when it was known that Saffron’s head was trapped.

But he said that controllers had to go through an algorithm, asking questions prompted by their computer.

He also admitted there were difficulties as the software had been designed for use in the United States, which has a different emergency response system to the UK.

Coroner Darren Stewart OBE suggested that the system was ‘rather clunky’ and had led to ‘a muddled response’. He added that it appeared to have ‘straitjacketed’ the controller into a particular line of questioning and asked: ‘Where’s the common sense?’

Mr Strutt explained call handlers were ‘obligated to ask key questions’, but a more experienced handler could have moved on ‘at a quicker pace’.

7.57pm

A two-person ambulance crew was dispatched by the Ambulance Service from Beccles, around a ten-mile drive away.

Over the next three minutes the call handler seemed slow to appreciate the imminent danger Saffron was now in.

Mr Joy: ‘Okay, if she’s trapped do not move her unless she is in danger okay?... Would we have any problems easily reaching her...’

Caller: ‘Yeah because she’s under a rock.’

Mr Joy: ‘...Stay on the line... so we’re advising to not attempt to rescue her and wait for the ambulance crew to arrive okay and tell her not to move. Do you know her name?’

Caller: ‘No, I don’t know her name but they’re trying to help her – she’s in the water now... the water’s rising and going under the rock. Would you be quick please?’

Mr Joy: ‘Yep we’re coming as quickly as we can. Tell the people who are with her to not attempt to rescue her and tell her not to move, okay, do that for me now?’

Caller [shouting to others]: ‘The ambulance is telling her not to help you.’

Mr Joy: ‘I’m telling them not to not help, but not to move her until the ambulance crew arrive if she’s trapped under the rocks.’

Caller [shouting to others]: ‘They’re saying not to move her. She’s going to drown she’s in the water.’

Mr Joy: ‘Okay, is her head in the water?’

Caller: ‘Yes, her legs are the only thing reaching out from the rocks – and she’s going to drown soon.’

Mr Joy: ‘So how exactly is she trapped?’

7.58pm

The Ambulance Service called the Coastguard Rescue HQ.

7.59pm

Having been advised Saffron was now in the water, the incident was ‘escalated’ by the ambulance service to a potential ‘drowning’ incident.

At 8 minutes and 45 seconds into the call, the caller reported that Saffron was ‘now under the water and has passed out’. She added just over 30 seconds later: ‘She is unresponsive.’

The caller appeared exasperated at the wait for help, saying: ‘How long is it going to be because I think she is going to die...’

8.02pm

A rapid response ambulance vehicle was also tasked with attending in the hope it would get there quicker. The ambulance service called police.

8.03pm

The call continued.

Mr Joy: ‘You’re doing really well, just keep me updated and if she starts responding or anything else happens, let me know okay?’

Caller: ‘Well she’s under water she can’t respond.’

Mr Joy: ‘No, I appreciate she’s under water at the moment but if that water lowers and she starts responding, let me know.’

Caller: ‘You can’t see her face.’

8.04pm

Caller: ‘Ugh, where are they?’

Mr Joy: ‘They’re coming as quickly as they can, I can’t exactly tell you where they are, they’re on their way.’

Caller: ‘Can they come as quickly as they can? I think she’s died.’

8.05pm

Thirteen minutes after the 999 call was made, the Ambulance Service finally called Suffolk Fire and Rescue Service – but did not make it clear exactly what was happening or whether they were needed.

‘Just to let you know, we have a job ongoing for someone who’s trapped in some rocks,’ the call began. ‘The water has submerged her. We are en-route with the Coastguard and wonder if you’d like to come along.’

The fire service was unclear if they were actually needed, as they do not routinely go into the sea to carry out rescues, adding further delay as they attempted to clarify.

8.06pm

Dover Maritime Rescue Co-Ordination Centre received a call from the Fire Service querying if they were needed.

8.09pm

The Fire Service called Coastguard Rescue HQ which confirmed the fire service was needed because Saffron was trapped.

8.10pm

The ambulance rapid response vehicle arrived on the scene with paramedic Colleen Gibson inside.

She had joined the service in 2018 as a student paramedic and had attended four water ‘incidents’ in her career. Giving evidence to the inquest, she broke down in tears a number of times.

As part of her training she told the inquest she had learned that there was a 30-minute window in which to rescue someone who had been under water in conditions such as those on that day.

On arrival, standing on the esplanade, Ms Gibson was able to see the trapped woman.

’I felt unable to make a rescue and, now, being 20 minutes submerged...’ she told the hearing.

Referring to the 30-minute time frame to save a drowning person, Bridget Dolan KC, counsel for the inquest, asked: ‘Did you not say, “It’s not for me to rescue, but we still have ten minutes”?’

Ms Gibson said: ‘No, I did not.’

Asked why she didn’t say that to the Coastguard or police she said: ‘I do not know.’

The hearing heard that Ms Gibson made a call back to control, in which she said: ‘The water’s come in ten minutes before we arrived.’

This would have in fact meant there were 20 minutes remaining to save Saffron.

Ms Dolan suggested that this was correct, and that Ms Gibson may have been told this at the scene by witnesses.

However, during the inquest Ms Gibson reiterated that she was told several times by witnesses that Ms Cole-Nottage had been unresponsive since 7.52pm, which would mean 20 minutes had already passed and ten remained.

Ms Dolan said that police officers who attended said they would have tried to rescue Ms Cole-Nottage if they thought she could have been saved.

Bodyworn video footage showed a police officer asking her if anything could be done to save Saffron to which Ms Gibson replied: ‘No.’

Ms Dolan said Ms Gibson described Saffron as ‘clearly deceased’ and that nothing could be done to save her.

‘Might it have been that you had come to the view she was clearly deceased […] and that may have affected how you thought afterwards?’ Ms Dolan asked.

Ms Gibson said she did not know.

Expert witness Professor Richard Lyon, an emergency medicine consultant, told the inquest the 30-minute rescue ‘clock’ should have been started from when Ms Gibson arrived – not before.

Meanwhile, Matthew England, a nurse and paramedic who sits on a group that advises the Home Office about emergency service responses, said Ms Gibson should have taken command of the scene as the first responder there.

8.11pm

Coastguard arrived on scene.

8.12pm

The ambulance arrives with paramedic Billy Seaman on board.

He described a ‘disjointed’ operation in which responders effectively ‘winged it’.

While on the way, he had tried to access guidance on how to respond to a drowning incident but was unable to find any information.

‘Since my training in 2014, Saffron was the first patient I had been to who had drowned,’ Mr Seaman said.

He later added: ‘We are supposed to have annual training, but it is not always delivered.’

Describing the conditions, Mr Seaman said: ‘It was dark… I stood on the railings. I just saw Saffron’s leg, that’s all I saw.’

He admitted he ‘hadn’t really been prepared for how severely stuck she was’.

8.14pm

Acting Sergeant Alex Allport and Temporary Police Sergeant Matthew Holmes arrived at the scene.

Sgt Allport said that when he arrived he was only told there was ‘somebody on the rocks’. He added that the only thing a coastguard told him was ‘body recovery’ while the first thing he heard a paramedic say upon his arrival was ‘clearly deceased’.

Describing Saffron’s condition, he told the court there was ‘no movement, no sound’ and her leg was in a ‘rigid unnatural position’.

Later, under questioning from Saba Naqshbandi KC, counsel for the family, Sgt Allport said ‘rigor mortis’ appeared to have set in.

The officer repeatedly highlighted both a lack of training and the dangers responders faced. ‘Slippery conditions and lack of equipment. We’re not trained in any incident of that nature,’ he said.

8.19pm

Lowestoft Coast Rescue Team arrived on the scene in a coastal rescue vehicle.

8.22pm

Eleven minutes after being tasked – and exactly 30 minutes after the first 999 call – Sebastian Herrod arrived at the seashore, the first of 12 firemen sent to the scene. The officers were immediately struck by the lack of activity from the other emergency services.

There was no cordon and no blue lights. A lone police officer was shining a torch on Saffron’s legs while two members of the Coastguard told them that they were not equipped with PPE suitable for the location. Ambulance crew and the Coastguard informed them that Saffron was dead.

8.26pm

The first fire crew personnel arrived at Saffron’s side.

Fireman Ben Whale told the inquest that, given the cold conditions – which can help conserve life – even if underwater for 30 minutes she could be saved. Six years earlier he had rescued someone trapped in a similar situation on the Lowestoft seafront.

‘I had a brief conversation with a uniformed police officer who said they believed it was a body recovery but did not give me any information other than that,’ Mr Whale told the inquest.

‘It did not feel quite right to me. I turned immediately into fire service communication mode. I was making communication: “Hello, can you hear me, it’s the fire service”. I was trying to gain some form of assessment myself.’

Another firefighter, Richard Lark, said he felt Saffron’s leg and it was still warm and he believed ‘there was a high chance she could be in a pocket or gap in the rocks allowing her to breathe’.

8.28pm

The fire crew at the scene decided ‘in a matter of ten seconds’ to attempt to rescue Saffron – it took between 30 seconds and a minute to free her.

It was now approximately 37 minutes since the emergency call had initially been put through to the ambulance service.

Two firemen in protective gear held on to Saffron and the two firemen not in protective gear were down on the rocks holding on to them.

‘It was quite a simple manual manipulation,’ said Mr Whale. ‘A small push for a large pull.’

Mr Whale told the inquest that even the two firemen in protective gear could have managed to free Saffron on their own.

At an earlier hearing it was suggested that the rising tide might have aided her extraction at this point – the water giving buoyancy to Saffron’s body.

8.30pm

Firemen started CPR at the scene before Saffron was carried up to an ambulance. Clearly feelings were running high – the inquest heard that a fireman swore at the ambulance crew because they would not bring life-saving equipment down to the rocks.

According to fireman Mr Herrod, ‘the ambulance crew were reluctant to go over the lower sea wall’ to the casualty so Saffron was carried up to them on the promenade. The inquest was told that they had not been down to assess her because of a lack of PPE.

The inquest also heard from an expert who said it wouldn’t have been safe for paramedics to attend to Saffron by the rocks and moving her gave them 360 degree access.

8.35pm

An East Anglian Air Ambulance helicopter which had flown from Norwich landed at the scene at 8.35pm.

8.44pm

Efforts to resuscitate Saffron were stopped. A post-mortem examination would later confirm her cause of death as drowning.

Additional reporting: Stephanie Condron