A baby boy who died within 24 hours of falling ill faced a delay in being taken to hospital, an inquest heard.
Paramedics called out to three-week-old Alfie Parkin did not take him immediately.
Even when an ambulance arrived, the handover was slow and an oxygen mask was too big for his face and kept falling off.
The tot suffered a cardiac arrest in the ambulance which triggered an internal investigation at Yorkshire Ambulance Service.
Following Alfie’s death from a rare genetic condition, the service has now changed the way it handles small babies.
“I do think there are lessons to learned here,” said Sheffield assistant coroner Louise Slater as she recorded a verdict of natural causes.
The inquest heard Alfie, who lived with parents Neil and Amanda Parkin on Sussex Road, Chapeltown, died from adrenal hyperplasia.
Alfie’s grandfather rang for an ambulance at 1.17pm on May 29 last year when his grandson developed breathing problems.
The call handler assessed it as urgent but not life-threatening and said a clinician would call back within 20 minutes.
Alfie’s case was then regraded for an ambulance to attend within 19 minutes but it took a second call by Alfie’s dad before a rapid response vehicle was allocated.
Two paramedics arrived at 1.42pm and had concerns over Alfie’s colour and breathing but as he was moving in his mum’s arms they decided to assess him further.
When a back-up ambulance arrived at 1.51pm a lengthy handover and more observations were done before the ambulance set off for the Children’s Hospital.
YAS clinical manager David Graham said the first crew treated the baby ‘in an appropriate way’ and the second crew ‘felt it was serious but not life-threatening’.
He said ‘it would not have been appropriate’ for Alfie to be placed in the back of the vehicle and transported immediately.
Basic life support was given to Alfie in the ambulance after his cardiac arrest and he arrived at the Children’s at 2.36pm but doctors could not revive him. He was pronounced dead at 3.37pm.
Mr Graham said: “I don’t think the service could have prevented his death.”
Handover procedures between crews had been reviewed and paediatric critical care training for frontline staff is being undertaken in the light of Alfie’s death.
Checks on ambulance equipment for small babies are also being carried out, in particular the oxygen masks.
Dr Deirdre O’Donnell, paediatric consultant, said even if Alfie had arrived 20 minutes earlier the prognosis was not good. “On balance the outcome would probably have been the same.”