A paramedic's decision to stop trying to resuscitate a seven-year-old girl who had suffered a cardiac arrest after a severe asthma attack was "a gross failure to provide basic medical treatment", a coroner has said.
South Yorkshire assistant coroner Michael Mellun made the comments in relation to the death of Izabelle Easen, known as Bella, who collapsed and died at her home in Thorne, South Yorkshire, in 2008.
Paramedic James McKenna tried to revive the "lively and lovely" youngster but pronounced her dead after deciding there was no sign of life.
The coroner ruled today that this decision was taken no more than 11 minutes after Mr McKenna started his resuscitation attempt.
The paramedic was later struck off by a panel that heard how ambulance service guidelines stated all children should be given life saving treatment until they arrive at hospital.
Today, as he delivered a narrative conclusion, Mr Mellun said he could not rule that the failures in the care of Bella amounted to negligence because the chances she would have survived if she had been taken to hospital were so slim.
In his conclusion, the coroner said: "Whilst the continuation of basic life saving followed by advanced life saving and conveyance to hospital would have advanced her prospect of survival, on the balance of probabilities it is unlikely she would have survived."
Earlier, Mr McKenna told the inquest in Doncaster that he got the protocol wrong as he believed at the time that the requirement to always take young patients to hospital only related to babies.
But he said there were no signs of life in Bella and he believed that taking her to hospital would not have saved her.
The court heard that Bella had suffered from a severe form of asthma for about three years and had been admitted to hospital numerous times after attacks.
Mr McKenna said he began life-saving treatment after he arrived from Doncaster ambulance station in a car on April 9 2008.
He said he found Bella on the bathroom floor. She was pale, had blue lips and no pulse, he said.
The former paramedic described how he began basic life-saving treatment with the help of a police officer who arrived shortly after him.
But, he said, he could not apply any more advanced life-saving techniques because he was the only clinician there at the time.
Mr Mellun told the court: "I am satisfied there was a gross failure to provide basic medical treatment."
Earlier, consultant chest specialist Simon Taggart, who provided an expert review of the case, said the chances were that Bella would have died anyway.
But he said that there was a 5% chance she could have survived if resuscitation had continued and she had reached hospital.
Dr Taggart said: " If she has a 5% chance, that failing contributed to her death."
He said: " I view it that children are robust and should be given every chance."
Asked by the coroner if he wanted to say anything, Mr McKenna said: " I'm sorry the way things have turned out. I did what I thought was right.
"Whether it's down to training or not, I don't know.
"If it could have been any other outcome, I would have had it that way.
"If I had thought for one minute she hadn't reached that 20-minute limit (the minimum time paramedics should give CPR to adults before pronouncing death), I wouldn't have called it.
"There was no reason for me not to have transferred her to hospital."
The court heard from the two ambulance technicians who arrived at the house after Mr McKenna who said they were surprised he had pronounced "life extinct" on the young girl.
Dawn Holliday said: "I was very surprised. We left the ambulance running in the street and we expected to be picking up a child and taking them to hospital."
Mr McKenna was struck off in 2010 after the Health Professions Council (HPC) heard about Bella's case and other, separate incidents - including one in which he "behaved without compassion, feeling or tact towards the patient and his family".
Bella's family only found out that Mr McKenna had been disciplined and struck off years later, after a Sky News investigation.
The case is one of a number uncovered by Sky News in which relatives were not told about paramedics being disciplined after treating members of their families.
Bella's mother, Lorna Robinson, was not in court today but Bella's grandmother, Julie Hodson, said she thought Mr McKenna should have been prosecuted.
Ms Robinson has previously said it was "morally wrong" that she was not informed of the disciplinary action against the paramedic.
Mary Ann Charles, the family's solicitor, said the verdict "brings an end to a period of unimaginable pain and distress endured for far too long by those who loved Izabelle Easen".
Ms Charles said that Ms Robinson spent years blaming herself for not doing enough for Bella.
"In face she did everything she could," she said, "it was the health services which had failed her daughter."
Ms Charles said the Yorkshire Ambulance Service had admitted serious breaches of its duty of care to Bella but still did not accept liability for her death due to the slim chances of her survival.
She said: "However you look at it, it's a pretty appalling set of circumstances that sees a child die at home of a condition as commonly understood as asthma and the emergency services are there within minutes."
Giving evidence in today's inquest, Dr David Macklin, the deputy medical director of the Yorkshire Ambulance Service, apologised for not informing the family about what had happened at the time of the incident. He said procedures had been overhauled.