A call handler with the NHS non-emergency 111 service admitted he made mistakes under pressure in the way he dealt with the case of a teenager suffering a fatal suspected allergic reaction.
Ademola Dada said he did things very differently when taking a call during a busy period from the mother of 18-year-old Shante Turay-Thomas in September, including failing to act on information about the victim's nut allergy, not engaging with a clinician over her worsening condition, and not checking the caller's address was correct.
The 18-year-old student initially said she felt unwell, but her condition deteriorated significantly while her mother, Emma Turay, was on the phone to the 111 service from the family home in Wood Green, north London.
Ms Turay-Thomas, an aspiring lawyer, slipped into unconsciousness and died in hospital hours later.
Giving evidence as the part-heard inquest resumed at St Pancras Coroner's Court on Monday, Mr Dada admitted he made mistakes, but said his priority was not to deviate from the NHS Pathways symptoms assessment service in order to get an ambulance to the sick patient.
I think there are a number of things I didn't do correctly in this case. There are a number of things I would have done differently.
He said "in hindsight" he would have spoken to the patient directly to gauge how significant her breathing issues were.
The inquest previously heard how the patient's mother described to Mr Dada that her daughter had a rash, tingling at the back of her throat, and she might have eaten nuts.
Asked by coroner Mary Hassell whether he should have considered the prospect that Ms Turay-Thomas was having an allergic reaction, Mr Dada said: "In hindsight, yes, it would have been appropriate to ask.
"But thinking back to what happened that night, I think I was wanting to get that ambulance out."
He added: "If I was to go back in time, I would ask more questions."
Mr Dada said he was often told by clinicians that some information was deemed unnecessary, and that call handlers are asked to keep details "short and sweet".
He said: "Most of the time you are shut down (by clinicians), you don't give them information you have not assessed."
But he said the reason he did not pass on the detail about a possible allergic reaction in this case was because he "didn't feel it was relevant at the time".
He added: "I should have thought of it, asking for a clinician's help.
"There was a high level of stress at the time, the service was busy at the time.
"I did it (processed the call) very differently. Even if it was not wrong, I did it very differently." The call was later passed on to a clinician.
Mr Dada told the inquest he only knew there was a serious problem when he went for a break 20 minutes later and saw the clinician who took Ms Turay's call with "his face in his hands".
The inquest previously heard Ms Turay-Thomas tried to save her own life with a self-administered adrenaline shot she had never been trained to use.
The inquest previously heard one ambulance was initially dispatched to the victim's grandmother's house six miles away, despite Ms Turay giving her Wood Green address several times.
Ms Turay was present in court on Monday, clutching a framed photograph of her daughter.
The case is listed to last until at least Thursday.