A woman who drowned after getting stuck headfirst in sea defence rocks might have been saved if the ambulance service had alerted the fire service quicker, a coroner has said.

Saffron Cole-Nottage, 32, was walking the family dog with her daughteron the seafront at Lowestoft, Suffolk, when she fell as the tide was coming in on 2 February 2025.

A girl called 999 at 7.52pm and within the first 30 seconds of the call explained to an ambulance service call handler that Cole-Nottage was “caught head down in the rock” by the seafront.

At 7.57pm and 7.58pm the caller made reference to Cole-Nottage “screaming”, before stating a minute later that she was “in the water now”.

Suffolk fire and rescue service was the last of the four emergency services to be notified, with the first communication to them being at 8.04pm.

Firefighters were on the scene at 8.22pm and the Suffolk area coroner, Darren Stewart, said it took them less than half a minute to free her after the first hands were placed on her at 8.29pm.

Cole-Nottage, a cleaner, was declared dead at 8.44pm.

The coroner, recording a narrative conclusion, said Cole-Nottage had “died from drowning which has come about due to accidental circumstances”.

Stewart said the East of England ambulance service “didn’t immediately contact the fire service”.

He added: “Had the Suffolk fire and rescue service been immediately alerted to the incident … it’s possible that Saffron would have been extricated from the rocks sooner and survived. However, it’s not probable she would have done so.”

The coroner said he would write to the chief executive of the East of England ambulance service and the head of NHS England with a series of concerns, including the time taken by the ambulance service to identify that the incident was a rescue during the 999 call and to pass that information to the fire service.

The coroner said he was also concerned that there had been a “failure” to follow guidance from the Joint Royal Colleges ambulance liaison committee that says a submerged person should be treated as a rescue for a minimum of 30 minutes.

Stewart said the clock should start on that 30 minutes when a first responder arrives on scene and confirms the person is submerged, and that the first paramedic to arrive had made a “premature decision to consider Saffron to be deceased”.

Earlier in Friday’s hearing, Stewart said the 999 call handler had told the caller not to try to rescue or move Cole-Nottage after the caller had said she was in the water.

Stewart said: “This was an extraordinary message to pass on regarding someone who had just been communicated to be trapped and at risk of drowning.

“This advice appears to have been a result of slavish adherence to the entrapment protocol which was still being followed at this stage (before later moving to a drowning protocol).”