A three-month-old baby girl died after an ambulance dispatched to attend to her got lost twice and then stopped to fill up with fuel.
Bella Hellings suffered a fit and stopped breathing at her home in Thetford, Norfolk on March 11.
Her mum Amy Carter called 999 at around 11am. It was the third time she had contacted the emergency services for Bella - the first time crews had arrived in two minutes and revived the little girl, while on the second occasion she was promptly taken to hospital.
On the third occasion, it is alleged that a series of 'failures' took place during what the Mail reports as the 'the critical 26 minutes it took an ambulance to reach the patient'.
East of England Ambulance Service Trust (EEAST) launched its own investigation into the circumstances of Bella's treatment and found a 'catalogue of errors'.
It states that the ambulance crew who were initially called were 30 miles away treating a patient. A second crew were just five miles away and free, but were not dispatched, while the vehicle that was sent to attend to Bella got lost twice and then stopped to refuel.
When the ambulance finally reached Bella's street, the driver – who was on her first shift - couldn't find the house, despite the fact that other ambulances had not struggled to reach it before.
An air ambulance carrying a doctor was also dispatched to the scene, but no-one had told the paramedics already with the little girl, and so they transferred her to hospital.
The ambulance then got lost again as it made its way back to A&E, even though Bella's mother was shouting directions to the driver.
The Mail reports that when the vehicle finally made it to the hospital, the crew did not know how to work the lift on the ambulance, and a paramedic carried Bella inside the building.
By the time Bella was seen by a doctor, she had not been breathing for almost an hour and was pronounced dead.
Her outraged family claim the paramedics insensitively joked about creaking knees when they first bent down to pick Bella up, and 'casually talked about their weekend' as they drove to hospital.
EEAST has already come under criticism for other tragedies. It is now reportedly 'recruiting more frontline staff to improve its service'.
Bella's parents have said the trust is a 'shambles'.
In a statement Amy and Bella's dad Scott Hellings said:
"We see this report as an important first step towards establishing the facts and ensuring a dramatic improvement in the ambulance service. It was a catalogue of errors. The report portrays an organisation in a complete shambles.
"Little Bella was one of five patients to die following ambulance delays during March alone. For years it was known there was an alarming problem, but warnings went unheeded.
"There is however no evidence that staff on the ground were responsible for the problems, and we can only wonder what their morale must be like."
The family's lawyer said they will consider their legal position after the inquest into Bella's death is held in September.
A spokesman said that 'a thorough internal investigation has taken place' and that the findings 'have been shared as appropriate ahead of the coroner's inquest'.