Source · Prevention of Future Deaths
Esmee Polmear
Ref: 2016-0203
Date: 27 May 2016
Coroner: Elizabeth Carlyon
Area: Cornwall
Responses identified: 0 / 2
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Failure to routinely use respiratory rate benchmarks, oxygen blood monitoring, and recognise critical red markers in paediatric respiratory medicine hindered diagnosis and treatment.
Date
27 May 2016
56-day deadline
22 Jul 2016 est.
Responses identified
0 of 2
Coroner's concerns
Failure to routinely use respiratory rate benchmarks, oxygen blood monitoring, and recognise critical red markers in paediatric respiratory medicine hindered diagnosis and treatment.
View full coroner's concerns
_ At the inquest Ihe Paediatric Expert, Igave the opinion (hat The routine use of respiratory rate bench-markers in paediatric respiratory medicine The use of rouline oxygen blood monitoring in paediatric medicine The recognition and action on red markers (which in this case were shortness of breath, chest pain and blue lips) Would have assisted and improved the chances of diagnosis and treatment of Esmee and other children,wilh a view to preventing_future deaths or providing day flag appropriate treatment and palliative care in life limiting cases
Report sections
Investigation and inquest
Esmee Polmear died on 1st July 2015 and an investigation commenced on 15th July and an inquest was opened on 20th October 2015 A full hearing was held on 13th April 2016
Circumstances of the death
Esmee Polmear (DoB 13.03.08) felt ill whilst going on a school trip from her Primary School in Perranporth; to Perranporth Beach on the morning of the 18t July 2015. On her return she collapsed and went into cardiac arrest; Paramedics attended and she was transferred to the Royal Cornwall Hospital where despite attempts at resuscitation she was recognised dead: She died from Pulmonary veno-occlusive disease which is a rare life limiting condition: She had been under the investigation of her GP and the Royal Cornwall Hospital, Paediatric services in the months prior to her death but her condition was not diagnosed or recognised prior to death:
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to lake such action: And that you are undertaking your own reviews and investigations into this death with a view to Local and Nationwide learning: In order to assist (with the consent RCHT and St Agnes Surgery) attach St Agnes surgery root cause analysis incident no 2015#24302 Royal Cornwall Hospital, Treliske, Truro Serious Incident Report 2015/24302
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Report details
- Reference
- 2016-0203
- Date of report
- 27 May 2016
- Coroner
- Elizabeth Carlyon
- Coroner area
- Cornwall
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 22 Jul 2016 (estimated).
Sent to
- Kernow Clinical Commissioning Group
- NHS England