Ambulance workers were guilty of “gross failings to provide basic care” in the death of a 15-year-old schoolgirl from meningitis, a coroner has ruled.
Zara Cheesman, who died at the Queen’s Medical Centre (QMC) in Nottingham in December, had shown “red flags” of the disease, and might have survived but for the “neglect” of East Midlands Ambulance Service (EMAS), coroner Elizabeth Didcock said.
Concluding the inquest into the schoolgirl’s death at Nottingham Coroner’s Court on Wednesday, Ms Didcock said she was “satisfied neglect contributed to Zara’s death”.
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She added: “In this case, it is the total picture of the EMAS assessment that amounts to neglect.”
Two technicians who assessed Zara and did not take her to hospital were guilty of “gross failings to provide basic care”.
Ms Didcock said there was an opportunity missed “to provide treatment on the 21st of December 2024 that likely would have been lifesaving”.
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The teenager, from the Mapperley Park area of the city, went to A&E the day before after vomiting and suffering from neck and shoulder pain, but she was discharged with a suspected case of norovirus.
Dr Derek Huffadine, a paediatric emergency medicine registrar at QMC, considered Zara might have meningitis but decided not to do blood tests because he didn’t think they would help on the basis of his examination.
This conclusion was “reasonable”, the coroner said, as was the decision not to order tests.
The next day, Zara woke up “confused”, so EMAS technicians, who, unlike paramedics, are non-registered clinicians, went to Zara’s home.
Ambulance service policy is for technicians to ask for guidance from a registered clinician if they decide not to take a child to hospital.
They did not follow it and Zara would likely have survived had they done so, the inquest heard.
The technicians had a preconception that Zara had norovirus and did not consider the significance of her not being “with it” and ignored her parents’ concerns, Ms Didcock said.
There was “no exploration of these key symptoms”, a history of diarrhoea was incorrectly recorded, and they did not follow guidance, the coroner added.
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She said: “I find all of the above failings amount to serious issues of care. Had Zara been conveyed to hospital, she would have had an appropriate assessment. On balance, Zara would have survived.”
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Speaking outside Nottingham Coroner’s Court, Zara’s mother said losing their daughter “has left a hole in our lives that can never be filled. She was empathic, funny, intelligent and had so many dreams she wanted to achieve – a daughter, a sister, and a friend whose laughter lit up the room”.
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Her father said: “Our deepest wish is that the lessons are learned, and actions are taken so no other family will be forced to endure what we have been through.”
Keeley Sheldon, director of quality at East Midlands Ambulance Service, said: “I am truly sorry that we missed the opportunity to take Zara to hospital for further assessment.
Offering her “sincere condolences”, she said EMAS accepted the coroner’s findings and promised to make changes “to ensure that this does not happen again”.
