“She was my world, she was my shadow,” Ms Ticehurst said on Wednesday.

She was speaking to Coroner Hugh Dillon at the inquest into the death of the 12-year-old. Lizzie died after an asthma attack at the Griffith Show on September 30, 2012. “She was a lovely little girl,” Ms Ticehurst said as she struggled to hold back tears.

“She had such lovely long black hair. She was beautiful. I miss her so much.”

Ms Ticehurst said she regretted allowing Lizzie to attend the Griffith Show. “It’s so hard every day. I can’t even go there (the showground). I can’t even go past it because I can still see her there.”

Ms Ticehurst recalled the night Lizzie died. She said she feared the worst when she arrived at the showground. “I was saying to myself ‘come on Liz, come on my girl’.” The inquest heard from NSW Ambulance control centre assistant Kelly Matthews, who answered the Triple-0 call. She told the inquest that protocol about how to deal with calls was different from what it was when Lizzie died.

Ms Matthews was asked about protocol and at what point an ambulance can be dispatched. She said when she answered a call the phone number the person was ringing from automatically appeared on the computer screen.

However, she was required to ask them for a contact phone number before she could process the request for an ambulance to be dispatched. She said protocol now allowed her to read back the phone number that appeared on the screen and ask the caller if that was their contact number. Ms Matthews said she was initially told by the caller the patient was not breathing.

Counsel Assisting the Coroner Dr Peggy Dwyer read part of the call transcript to Ms Matthews. The caller said there was a girl who couldn’t breathe.

Ms Matthews was then told “you need to hurry up”.

Dr Dwyer said Ms Matthews found out the road the ambulance needed to enter the Griffith showground from 47 seconds into the conversation, but the information was not sent to dispatch until three minutes had passed. 

Ms Matthews said there was further information she had to input into the computer to allow the request for assistance to be sent to dispatch.

The information sent to dispatch said Lizzie was breathing, despite the caller initially saying she was not.

Ms Matthews said she was told during the call Lizzie was unconscious but was breathing and she could hear people in the background saying she was breathing.

Ms Matthews said if she had been able to establish Lizzie was not breathing she would have given instructions for someone at the scene to commence CPR.

Ambulance NSW assistant commissioner James Vernon expressed his sincere condolences to Lizzie’s parents when he was in the witness stand.

He confirmed the protocol regarding asking for a caller’s phone number had been changed following the incident and conceded there was enough information one minute into the call on September 30 to dispatch an ambulance.

Mr Vernon said Ms Matthews followed protocol when it came to trying to establish whether Lizzie was breathing. The inquest also heard from pediatrician Dr Christine Norrie.

She said possible triggers for an asthma attack on the night may have been dust, physical exertion and the possible presence of people smoking at the event.

Dr Norrie said she believed bystanders should have commenced CPR if Lizzie was having difficulty breathing.

Mr Vernon said Ambulance NSW did not advise people to administer CPR unless a person had stopped breathing.

He said Ambulance NSW was always working to improve protocol and the way it responded to Triple-O calls.

Mr Vernon said he was part of the Next Generaton Triple Zero strategy to look at how to allow people to report emergencies via an SMS or social media.

He also said Ambulance NSW was working on having access to the location of mobile phones to making responding easier.

Paramedic Sharon Miller also gave evidence at the inquest.

She said she remembered there was limited lighting at the showground.

Ms Miller said an SES member held a torch for her while she was at the scene.

Coroner Dillon said it was unclear what had triggered Lizzie’s asthma attack on the night.

He said it could not be determined whether assistance from someone with first aid training would have resulted in a different outcome.

He praised the efforts of paramedics who responded to the call.

He said Ambulance NSW’s system for obtaining information was helpful and provided high quality, accurate information.

Coroner Dillon said the show committee should have had temporary lighting in place at the event.

He said the overemphasis on obtaining a telephone number was unnecessary.

He said Lizzie died from a cardiac arrest.