Zara Cheesman, 15, died of meningitis in December last year after being discharged from A&E being told her vomiting and neck pain were most likely a case of norovirus
A 15 year old girl tragically lost her life to meningitis after an ambulance service “failed” her by not taking her to hospital, an inquest has heard.
Zara Cheesman, from Mapperley Park, Nottingham, should have been rushed to hospital by East Midlands Ambulance Service (EMAS) workers before she passed away on December 23 last year, according to Nottingham Coroner’s Court. The schoolgirl had visited A&E on December 20 with symptoms of vomiting and neck and shoulder pain, but was sent home with a suspected case of norovirus.
The next day, two ambulance technicians, who are non-registered clinicians unlike paramedics, attended Zara’s home where she displayed “red flags” for meningitis such as confusion and a severe headache.
The inquest heard that it was policy for technicians to seek advice from a senior clinical lead if they decide not to take someone under 18 years old to hospital, but this protocol was not followed in Zara’s case. The inquest previously heard that Zara likely would have survived if she had been taken back to hospital.
Susan Jevons, head of patient safety for EMAS, expressed her deepest apologies to Zara’s family and vowed to make changes to prevent such a tragedy from happening again. She stated: “We failed Zara in life, we are not going to do that in death.”
Ms Jevons emphasised that it was the responsibility of each staff member to ensure they had read and understood policies, which are presented as bulletins that clinicians need to confirm they have read. The inquest heard that the technicians who attended Zara’s home claimed they were unaware of the policy regarding seeking guidance for under-18s, but Ms Jevons stated that Michael Hoy, a qualified technician as opposed to the other who was a trainee, had clicked a button confirming he had read it.
On Friday, while giving evidence, 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 mentioned that the policy for technicians to consult a registered clinician before discharging a child had been in place for “many, many years”.
The coroner asked: “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 confirmed that there have been no similar incidents since Zara’s tragic passing and that all children who have needed hospital treatment have been taken by ambulance crews. She turned to Zara’s family at the end of her testimony 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 concluded on Friday and the coroner is anticipated to deliver her verdict on Wednesday afternoon.