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The death of a student told to dial 999 as she gasped for breath outside a hospital has forced an NHS Trust to include car parks in its 'treatment areas'.
Pretty Melody Davis died from swelling on the brain two weeks after suffering an asthma attack at the Royal Liverpool University Hospital, an inquest heard.
As the 20-year-old sat in the car a friend ran into the hospital reception to plead for help but was told 'phone for an ambulance' despite Melody being just 50 yards from A&E.
Liverpool Coroner's Court heard the decision to take Melody to the hospital by car rather than call paramedics had 'put her chances of survival at risk'.
Melody's two friends, Grace Kelly and Elizabeth Port, frantically tried to get help when the attack began on 12th October 2010 - but neither had a mobile phone.
Instead the pair took the decision to drive her to hospital in a private car.
On the way to the city centre hospital Melody was in "severe distress", her head out of the window battling for air, she even tried to get out of the vehicle in panic.
When they arrived at the hospital car park in Mount Vernon, Elizabeth ran into the reception to plead for help for her stricken friend.
She was told she had to call 999, and despite her screams of dismay she was turned back to the car, where Grace was supporting "swaying" Melody to the entrance.
She collapsed before reaching the door and an ambulance arrived to take her the few yards to the A+E department.
Merseyside Coroner Andre Rebello told the court the ambulance came from another location in the city centre and was on service to another hospital.
A post mortem examination found that Melody, from San Jose, California, died from hypoxic brain injury brought on by acute bronchial asthma.
As Mr Rebello discussed the findings with forensic pathologist Dr Peter Good and asthma expert Dr Simon Taggart, Melody's father Roy listened via a telephone link from the USA.
Mr Davis told the court about his daughter, who had moved to Liverpool to study English Literature at the University of Liverpool.
He said: "She started in the fall of 2008 and had been studying for two years, but would come home for the summer.
"Melody was in her third year and would have graduated the following summer.
"She was interested in English culture and knew about Liverpool because of The Beatles and her research into the country, so she chose to go there."
The death of Melody Davis prompted widespread outrage at the seemingly inflexible hospital procedures.
Mr Rebello told the court of the findings presented in the report by Dr Taggart, who claimed that the "decision to put Melody in the car was the wrong one".
He continued: "Paramedics carry the appropriate equipment in case of an asthma attack of this nature and calling 999 would mean the medicine is brought to them."
Similarly the findings from Dr Good stated that "lack of awareness" was a factor in deaths caused by asthma attacks.
Dr Good wrote: "The decision to travel by car is a common factor in deaths through asthma attacks.
"At the time of arrival she was one to two minutes from respiratory arrest and no amount of emergency care would have saved her."
Despite The Royal Liverpool Hospital changing its policy on treating patients in a car park following Melody's death, Mr Rebello declined to apportion blame.
Tearful Mr Davis asked the coroner if staff at the Royal Liverpool Hospital were at fault, but Mr Rebello he would not to attach "culpability" to the NHS.
He also told the grieving father, who lives with his wife Dorothea in San Jose, that Melody's friends acted in her best interests.
Mr Rebello told Melody's father: "I am sure you would have liked attention to have been given in a different way when Melody arrived at the hospital.
"But the experts say that was not causative to her death.
"I'm hoping that the tragedy and upset you have suffered will enable other parents to take heed of the advice and to phone 999.
"In that way Melody's death would not have been in vain."
Verdict: natural causes.
A spokesman for the Royal Liverpool University Hospital said: "Our thoughts are with Melody’s family at this time and we would like to again offer our heartfelt sympathies.
"We note the comments of Dr Taggart, the asthma expert, in this case about the need to educate the public and asthma sufferers on the importance of using the emergency ambulance services.
"Since this tragic incident, the Trust has reviewed its policy for responding to medical emergencies within the hospital grounds. This includes advising the public on the need to contact the emergency ambulance services."
