A teenage girl who had bacterial meningitis could have been saved if it weren’t for ‘neglectful’ ambulance staff, a coroner has ruled.
Zara Cheesman, 14, died at the Queen’s Medical Centre in Nottingham on December 24.
The A* student had begun feeling sick on December 21, having gone to A&E after vomiting and suffering from neck and shoulder pain.
Hospital staff discharged her with a suspected case of norovirus, a stomach bug that causes nausea, vomiting and diarrhoea.
But Zara actually had meningitis, a rare disease that causes inflammation of the membrane around the brain and spinal cord.
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The treatment Zara could have received for meningitis when she first felt sick ‘likely would have been lifesaving’, coroner Elizabeth Didcock said.
She said there were ‘gross failings to provide basic care’ when two technicians assessed Zara and did not take her to the hospital.
Dr Derek Huffadine, a paediatric emergency medicine registrar, had considered whether the teen had the condition but decided not to perform blood tests as he thought they wouldn’t be helpful.
This was a ‘reasonable’ conclusion, the coroner said. The next day, Zara woke up ‘confused’, so emergency medical technicians went to her home.
Technicians, unlike paramedics, are clinicians who aren’t registered with the Health and Care Professions Council, a watchdog.
They typically work with a registered clinician while responding to urgent care incidents, according to the East Midlands Ambulance Service.
What is meginititis?
The illness is caused by infection with a bacterium called Neisseria meningitidis.
While it is common among babies, young children, teens and young adults, it can infect anyone of any age.
Typical symptoms include fever, headaches, stiff neck, vomiting, light sensitivity and drowsiness.
The bacteria can also invade the bloodstream and cause sepsis, a life-threatening response to infection that causes clammy skin, pain and chills.
As a bacterial infection, meningitis can be spread through sneezing, coughing or sharing utensils.
Up to one in every 10 cases of bacterial meningitis is fatal, sometimes in as little as 24 hours after diagnosis, according to the NHS.
So, medical professionals recommend people seek treatment as soon as possible to receive antibiotics. There are also various vaccines for meningitis, often offered to babies and teens.
But the coroner’s court heard that the technicians had a preconception that Zara had norovirus, so they did not ask for guidance from a registered clinician as required if they decided not to take a youngster to hospital.
There was ‘no exploration of these key symptoms’, a history of diarrhoea was incorrectly recorded and they did not follow guidance, the coroner said.
Didcock added that she will issue a prevention of future deaths report because she still has concerns about the ambulance service’s staff’s understanding of the policy around children.
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 added that Zara had long dreamt of becoming a human rights lawyer.
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,’ she added outside the court.
Zara’s 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.
‘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.’
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