Ambulance workers’ neglect contributed to the death of a teenager with meningitis, a coroner has found.
Zara Cheesman, from Mapperley Park in Nottingham, died on 23 December 2024 at Queen’s Medical Centre.
Concluding an inquest into the 15-year-old’s death at Nottingham Coroner’s Court on Wednesday, coroner Elizabeth Didcock said she was “satisfied neglect contributed” to the death.
“In this case, it is the total picture of the EMAS (East Midlands Ambulance Service) assessment that amounts to neglect.”
Ms Didcock said there were “gross failings to provide basic care” when two technicians assessed Zara and did not take her to hospital.
“There was an opportunity missed to provide treatment on the 21st of December 2024 that likely would have been lifesaving,” she added.
Speaking after the conclusion of the inquest, Zara’s parents Mark Cheesman and Judith Ramage said the inquest confirmed what they “long feared” – that Zara’s death was preventable.
“We’re devastated,” Ms Ramage said.
“East Midlands Ambulance Service failed in providing a basic level of care, dismissing our concerns and not assessing Zara appropriately. Indeed, they falsely reassured us.”
The inquest heard that Zara went to A&E on 20 December 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 that the girl might have meningitis but decided not to do blood tests because he “did not feel that blood tests would help” based on his examinations.
In her conclusion, the coroner said: “I find it was reasonable on the basis of the assessment to conclude that Zara had a viral vomiting bug.
“I find it was reasonable not to organise blood tests. I accept the evidence of Dr Huffadine that even if blood tests had been done, they would likely have been of limited value.”
The next day, Zara woke up “confused”, so EMAS technicians went to her home.
The technicians, who are non-registered clinicians unlike paramedics, should have followed ambulance service policy, which says they need to ask for guidance from a registered clinician if they decide not to take a child to hospital.
The inquest heard this policy was not followed and Zara was not taken to hospital, but she likely would have survived if she had been taken there.
The coroner said the significance of Zara not being “with it” was “not considered or explored” during the technicians’ assessment of the girl, and they did not listen to her parents’ concerns.
Ms Didcock said there was “no exploration of these key symptoms”, a history of diarrhoea was incorrectly recorded, the technicians had a preconception that Zara had norovirus and they did not follow guidance.
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.”
The coroner said she would issue a prevention of future deaths report because she still has concerns about EMAS staff’s understanding of the policy around children.
Zara was described as an A* student who wanted to become a human rights lawyer.
“Losing Zara has left a hole in our lives that can never be filled,” her mother said.
“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.”
Zara’s father Mr Cheesman added: “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. We will fight to honour our beautiful daughter Zara by advocating for change and getting justice.”
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. We deeply regret that we didn’t support Zara in the way she needed on December 21 2024.
“My sincere condolences are with Zara’s family and all who loved her, following her tragic death.
“We fully accept the findings of HM Coroner and will review the prevention of future deaths report alongside our existing internal review of this tragic case.
“We will make changes to ensure that this does not happen again.”
Gemma Bedford from Freeths Solicitors, representing Zara’s family, said in a statement: “The family welcomes the prevention of future deaths order and sincerely hopes that action is urgently taken to ensure lessons are learned.
“They hope that meaningful changes will be made to prevent other families from experiencing such a needless tragedy.”
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