Ambulance staff transporting an 81-year-old woman for mental health treatment needed coaching through CPR on the phone after calling hospital staff to say she was not breathing, an inquest has heard.
The inquest into Peggy Copeman's death continued with evidence from staff caring for the New Buckenham woman at Cygnet Hospital, in Taunton.
Mrs Copeman had been transported 280 miles to Somerset as no mental health beds were available in Norfolk and Suffolk, but died on the M11 while being transported back by private ambulance.
Jacqueline Lake, senior coroner for Norfolk, asked staff who treated the grandmother-of-two between December 12 and December 16 2019 about her physical health prior to being taken back to Norfolk.
Emily Sanderson, a health care assistant at the time, was one of three people bringing Mrs Copeman to the private ambulance driven by Premier Rescue Ambulance Service and took a phone call from the team at 2.30pm for her manager.
She asked if there was anything she could do to help before being told "Peggy's not breathing" and the ambulance had pulled over on the motorway and checking if Mrs Copeman was alive.
Miss Sanderson told the court: "They said we've pulled over on the hard shoulder. She is not breathing. I said have you rung an ambulance?
"I told them to hang up and call 999, which they did do.
"They rang Cygnet instead of dialling 999 like they should do."
Phoning back, Miss Sanderson told the staff member they needed to perform CPR while another colleague was speaking to a 999 operator.
"The lady on the phone was very distressed. Her breathing was very heavy. She sounded very distressed and I talked her through CPR," said Miss Sanderson.
The inquest heard Mrs Copeman was in the chair and that Miss Sanderson told staff they needed to get her on the floor "right now".
Calling 30 minutes later, she was told Mrs Copeman had died at the scene. On the first day of the inquest, it was heard her family was not told until after 7pm.
The inquest heard staff struggled to get Mrs Copeman to drink during the day, with 200ml to 400ml consumed in a daily period.
Miss Sanderson said the hospital aimed for patients to have at least 1,000ml a day.
Gail Heslop, a band five ward nurse at the time, took over the running of Mrs Copeman's ward on December 15 and said Mrs Copeman appeared dehydrated and described her as sunken, pallid, and having a dry mouth - and raised her concern in passing to Dr Olufemi Solanke in the corridor.
The nurse was running two wards on the day after a nurse on Swift Ward did not arrive but said with time she was able to get Mrs Copeman to drink 200ml of apple juice.
The inquest heard staff were instructed to check on Mrs Copeman every 15 minutes and Mrs Heslop said while on duty she reminded staff to offer her fluids.
She said: "She was the most poorly patient on the ward and I was concerned about her.
"If I thought there was an extreme risk I would ring 999 and call the duty doctor. I would contact the manager on call.
"I did feel she was poorly, I did not think she was so extremely poorly she needed that intervention."
Elaine Pinn, a health care assistant, who helped take Mrs Copeman to the ambulance said: "If we had any inklings of that we would have called the doctor to come before the transport left."
The inquest is due to continue for the rest of the week. On Wednesday, staff from the private ambulance firm are due to give evidence.
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