Source · Prevention of Future Deaths

Zara Cheesman

Ref: 2025-0481 Date: 25 Sep 2025 Coroner: Elizabeth Didcock Area: Nottingham and Nottinghamshire Responses identified: 1 / 1

Emergency medical services lacked detailed understanding of child assessment issues, relied on incorrect physiological scoring, and had insufficient audit, monitoring, and professional development for staff on paediatric guidelines.

Date 25 Sep 2025

56-day deadline 20 Nov 2025 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

1. There is no detailed organisational understanding of the extent of the issues identified in this case - that of the very limited assessment of a child or young person, the reliance on the incorrect physiological scoring system used, and the non-conveyance decisions made
2. There is insufficient audit and monitoring of EMAS operational staff by senior clinical staff, to ensure there is both understanding and following of key EMAS guidelines
3. There is insufficient continuing professional development for operational staff in respect of the assessment of sick children and young people, with frontline staff having limited knowledge and understanding of the Children and Young Persons clinical guideline (that includes the importance of listening to parents, physiological scoring systems in children, and the significance of a change in mental state of a child or young person) I am not reassured that necessary actions to address these serious issues identified are in place.

Responses

1 respondent

East Midlands Ambulance Service NHS Trust

3 Nov 2025 PDF

Action Taken

East Midlands Ambulance Service has implemented several actions including reviewing clinical governance, appointing a lead for children and young people, strengthening systems for paediatric assessment, expanding the clinical audit programme, and prioritising education on safe conveyance decisions involving children and young people. (AI summary)

View full response

Dear Dr Didcock

Re: Report regarding the case of Zara Cheesman deceased.

Thank you for your letter dated 25 September 2025 regarding the Regulation 28: Prevention of Future Deaths report following the inquest into the death of Miss Zara Cheesman.

East Midlands Ambulance Service (EMAS) is fully committed to learning from serious incidents and ensuring that our services continually evolve to meet the highest standards of patient care and safety. We have undertaken a comprehensive review of the concerns raised in your report and have implemented a series of targeted actions to address the issues identified.

Organisational understanding of the issues raised regarding clinical assessment of children and young people

Under the leadership of our new Clinical Director the organisation is reviewing our approach to clinical governance, leadership and supervision. Senior clinicians in the Trust have been appointed to lead specific areas including a lead for children and young people. We acknowledge the shortcomings in the assessment and conveyance decisions in Miss Cheesman’s case and EMAS is now strengthening its systems to ensure robust paediatric assessment and decision- making by our frontline clinical teams. All staff have access to the national ambulance clinical guidelines published by the Joint Royal Colleges Ambulance Liaison Committee (known as the JRCALC app) and these include specific guidance for febrile illness in children and medical emergencies in children. Confidential Dr Elizabeth Didcock Assistant Coroner for the Coroner Area of Nottinghamshire

These form the basis of our educational content and clinical practice. In addition, all clinical staff have access to age-appropriate tools via our electronic patient record system (ePRF), including the Paediatric Observation Priority Score (POPS2), implemented in collaboration with East Midlands Acute Trusts.

We have reinforced education around the appropriate use of physiological scoring systems, including NEWS2, through our annual training programmes and point-of-care guidance. A Trust-wide education initiative focused on paediatric conveyance decisions has been launched, supported by staff engagement events and a newly established working group to review policy effectiveness.

To ensure immediate impact, we have issued a clinical bulletin outlining essential paediatric care principles, including mandatory referral protocols for non-registered and newly qualified staff. Additionally, we have adopted the UK Sepsis Trust’s standardised tool for paediatric sepsis assessment and management.

Audit and Monitoring of Clinical Practice

We have expanded our clinical audit programme to include mandatory reviews of paediatric care episodes. This ensures that both remote and face-to-face interactions are assessed for adherence to clinical guidelines. To enhance oversight, we have introduced compliance tracking for clinical bulletins and integrated this into our performance monitoring structures.

Clinical support is available 24/7 via our central and divisional hubs, staffed by specialist clinicians and leadership teams. We also maintain strong links with external partners such as NHS 111, community teams, and specialist services, which are regularly utilised to support decision-making. As a part of developing our clinical leadership and supervision framework we have commenced a review of our remote support provision including the use of specialist and advanced paramedics.

Continuing Professional Development (CPD)

EMAS recognises the importance of ongoing professional development, including paediatric care. All staff have access to the nationally endorsed “Spotting the Sick Child” e-learning programme, and annual resuscitation training for children and young people is mandatory.

In 2025–26, we have prioritised education on safe conveyance decisions involving children and young people. We have also hosted multidisciplinary workshops to gather staff insights and shape future CPD offerings. Registered clinicians benefit from access to ParaPass and ParaFolio, which digitally support guideline-aligned learning and portfolio development.

I hope that this response provides you with the appropriate level of assurance in relation to our commitment to continuous improvement of our services.

Report sections

Investigation and inquest

On 27.12.24, I commenced an investigation into the death of Zara Alice Cheesman The investigation concluded at the end of the inquest on the 17th September 2025 The conclusion of the inquest was a Narrative as follows: Zara developed meningococcal meningoencephalitis, a devastating disease, with early symptoms likely beginning late afternoon on 19.12.24. These early symptoms were non-specific, and the assessment of Zara at the Childrens Emergency Department at Queens Medical Centre on 20.12.24 was reasonable, although it is likely that the meningitis was in its early phase at this time. The assessment on 21.12.24 by the EMAS crew, following parents again seeking help and advice as they had identified that Zara was now incoherent and confused, should have led to an admission to hospital, which would have led to treatment for the meningoencephalitis, and on balance Zara would have survived had this occurred. Zara’s illness continued to progress, and she became critically unwell, from the intracranial effects of the disease, such that by the morning of 22.12.24, the situation was irretrievable. The lack of recognition by the EMAS crew, of how unwell Zara was on 21.12.24, and the failure to following key EMAS guidelines, led to her non-conveyance to hospital on that day. This failure to convey her to hospital, has made a more than minimal, negligible or trivial contribution to her death. Zara’s death was contributed to by neglect

Circumstances of the death

Zara died on 23.12.24 at Queens Medical Centre, Nottingham from meningococcal meningoencephalitis. She had been unwell from late afternoon on 19.12.24, with initially vomiting, and a fever, then developing a headache, with worsening lethargy. She was seen in the Childrens Emergency Department at QMC, on the afternoon of 20.12.24, following advice from the 111 service.

The assessment by the two clinicians who saw her on that day was thorough, but incorrectly identified that Zara had a vomiting bug, rather than meningitis in its early phase. Zara then became confused with incontinence, and worsening lethargy over the subsequent hours, with development of a more severe headache overnight on the 20.12.24, which then seemed to settle. Family again appropriately sought advice from the 111 service around lunchtime on 21.12.24, as they were worried that she was incoherent, confused with episodes of incontinence, and continuing vomiting. The 111 service recognised that she required an urgent ambulance response, and an EMAS technician/trainee technician crew made an assessment of Zara at home. Despite family clearly setting out her symptoms and their concerns, the crew did not undertake an adequate assessment - there was neither an adequate assessment of the history of her illness, nor an adequate examination of Zara. The Technician attending did not recognise her new confusion, and did not recognise how unwell she was. The crew did not recognise that there was a requirement for discussion with a clinician, nor that she should have been conveyed to hospital for a necessary assessment and treatment. Zara continued to deteriorate, and family were understandably reassured that she had a vomiting bug, likely Norovirus, as Zara had now had two assessments that had not resulted in an admission. By the early morning of 22.12.24, Zara was critically unwell, with meningoencephalitis and brain swelling. Despite prompt attendance by EMAS and Helimed crews, and then all emergency management at the scene, in the Childrens Emergency Department and then in PICU, Zara died in hospital on 23.12.24. Accepting that meningococcal meningoencephalitis is a severe and life threatening disease that is rapidly progressive, and can be a difficult diagnosis to make in its early phase, there was an opportunity missed to provide treatment on 21.12.24, that would have likely been life saving.

Copies sent to

2. The Nottingham University Hospitals NHS Trust3. The Nottingham and Nottinghamshire Integrated Care Board

Inquest conclusion

Zara developed meningococcal meningoencephalitis, a devastating disease, with early symptoms likely beginning late afternoon on 19.12.24. These early symptoms were non-specific, and the assessment of Zara at the Childrens Emergency Department at Queens Medical Centre on 20.12.24 was reasonable, although it is likely that the meningitis was in its early phase at this time. The assessment on 21.12.24 by the EMAS crew, following parents again seeking help and advice as they had identified that Zara was now incoherent and confused, should have led to an admission to hospital, which would have led to treatment for the meningoencephalitis, and on balance Zara would have survived had this occurred. Zara’s illness continued to progress, and she became critically unwell, from the intracranial effects of the disease, such that by the morning of 22.12.24, the situation was irretrievable. The lack of recognition by the EMAS crew, of how unwell Zara was on 21.12.24, and the failure to following key EMAS guidelines, led to her non-conveyance to hospital on that day. This failure to convey her to hospital, has made a more than minimal, negligible or trivial contribution to her death. Zara’s death was contributed to by neglect

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Report details

Reference: 2025-0481
Date of report: 25 September 2025
Coroner: Elizabeth Didcock
Coroner area: Nottingham and Nottinghamshire

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 20 Nov 2025 (estimated).

Sent to

Chief Executive, East Midlands Ambulance Service NHS Trust (‘EMAS’)

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Data: judiciary.uk.

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