Girl, 15, who died of meningitis ‘failed’ by ambulance service, inquest hears

An unwell 15-year-old girl who died of meningitis was “failed” by an ambulance service when she was incorrectly not taken to hospital, an inquest has heard.

Zara Cheesman should have been taken by East Midlands Ambulance Service (EMAS) workers to hospital before she died on December 23 last year, Nottingham Coroner’s Court heard.

The schoolgirl, from the Mapperley Park area of Nottingham, went to A&E on December 20 after vomiting and complaining of neck and shoulder pain, but was discharged with a suspected case of norovirus.

The following day, two ambulance technicians, who are non-registered clinicians unlike paramedics, went to Zara’s home where she showed “red flags” of meningitis such as confusion and a severe headache.

The inquest was told that it was policy for technicians to seek guidance from a senior clinical lead if they decide not to take someone under 18 years old to hospital, but this was not done in Zara’s case.

The inquest previously heard Zara likely would have survived if she had been taken back to hospital.

Susan Jevons, head of patient safety for EMAS, apologised to Zara’s family and promised to make changes to ensure that the same thing does not happen again.

She said: “We failed Zara in life, we are not going to do that in death.”

Ms Jevons said it was the responsibility of each staff member to make sure they had read and understood policies, which come up as bulletins which clinicians need to confirm they have read.

The inquest heard that the technicians who attended Zara’s home said they had not seen the policy about seeking guidance for under-18s, but Ms Jevons said Michael Hoy, who was a qualified technician whereas the other was a trainee, had pressed a button to confirm he had read it.

Giving evidence on Friday, Ms Jevons said: “You are a clinician, you have a responsibility to us as an organisation and your patients that you are reading and understanding those policies and procedures.

“We cannot sit and take every clinician off the road to go line by line with every policy.”

She told coroner Elizabeth Didcock: “Because Zara had already had a presentation at the Queen’s Medical Centre the day before, there would have been no question – she should have been conveyed back to hospital.”

Ms Jevons said the policy for technicians to speak to a registered clinician before discharging a child had been in place for “many, many years”.

The coroner said: “How do I know those two (technicians) are unusual, they are outliers?

“Those things are not familiar to (Mr Hoy), yet every day he is making conveyance decisions or leaving patients there.

“I need to be confident across those that go out, there is an understanding of what is different about under-18s… those aspects are key to this awful situation for Zara.

“It’s key for young patients today, tomorrow – that’s the concern.”

Ms Jevons said there have been no similar incidents since Zara died and that all children who have needed to go to hospital have been taken by ambulance crews.

She addressed Zara’s relatives at the end of her evidence and said: “I’m so sorry we let you down. We will make sure we do make major changes to assist other patients.

“We can’t do anything for Zara, I’m truly sorry we can’t. I will make sure it does not happen again.”

The inquest’s evidence finished on Friday and the coroner is expected to deliver her conclusion on Wednesday afternoon.