Overview

• Assistant coroner Elizabeth Didcock concluded that neglect by East Midlands Ambulance Service technicians contributed to the death of 15-year-old Zara Cheesman.
• She ruled that had Zara been taken to hospital on December 21, 2024, she would likely have survived her bacterial meningitis.
• The technicians, who were not registered clinicians, failed to consult a registered clinician before deciding against hospital conveyance, contrary to EMAS policy.
• The court accepted that the A&E registrar’s decision the previous day not to order blood tests was reasonable, placing the critical failings in the subsequent ambulance assessment.
• The coroner cited confirmation bias, failure to explore key symptoms such as confusion, and incorrect recording, as EMAS apologized, accepted the findings, and pledged changes following the forthcoming report.