A six-year-old who died choking on a grape has had her death ruled as accidental at a Caernarfon inquest.
In August 2014, Jasmine Lapsley was at her family holiday home in Morfa Nefyn when she collapsed.
It took 25 minutes for an ambulance to reach her (the most life-threatening emergencies are meant to be met within eight minutes) before she was flown to Ysbyty Gwynedd by a rescue helicopter from RAF Valley.
The ambulance that reached Jasmine travelled 19 miles from Porthmadog. There were 21 incidents being dealt with at the time, nine of which were ‘red’ emergency calls.
Announcing there would be a prevention of future deaths report, coroner Nicola Jones said :”It's clear the Welsh Ambulance Service need to address a gap in air support during the hours not covered by air ambulance, 8pm to 7am."
Ambulance chiefs were also urged by the Mrs Jones to look at how cover may be improved during the summer, when rural areas have an influx of tourists.
The Welsh Ambulance Trust was also told it needed to ensure community first responders were retained, replaced when they left, and recruited.
Tracy Myhill, chief executive of the Welsh Ambulance Service, said: “What happened to Jasmine was an absolute tragedy and our thoughts and sympathies remain with Mr and Mrs Lapsley.
“We know that there are things we could have done differently, both during and after the event, and for that we are genuinely sorry. We began piloting a new clinical response model on October 1 which prioritises those patients in most need of care.
“We also need to improve the way we communicate with patients’ relatives. We have already looked at our family liaison support in light of this case, recognising we didn’t handle the aftermath of this tragedy well, which compounded the hurt and distress of the Lapsley family. This is unacceptable.”