Millie Elizabeth Josephine Thompson · Prevention of Future Deaths report

On the 26th October 2012 I commenced an investigation into the death of Millie Elizabeth Josephine Thompson. The investigation concluded at the end of the inquest on 5th December 2013. The conclusion of the inquest was that Millie died from a Choking and a conclusion of Misadventure was recorded by the jury..

On the morning of the 23rd October 2012 Millie, then aged 9 months, was taken to Ramillies Nursery in Cheadle Hulme, Stockport, Greater-Manchester. This establishment which is registered with OFSTED caters for children from age 6months to 16 years. Whilst she was being fed Shepherd’s Pie for lunch that day, she started to choke, she inhaled some of the food which eventually lodged in her left main bronchus, this led to her sustaining a tension pneumothorax leading to the cardiac arrest which was the underlying cause of death.

When the call was made to the Ambulance service, the call taker wrongly assessed and allocated it thus meaning that a Rapid Response vehicle was not despatched.

The crew of the first ambulance found that the oxygen mask that they had on their vehicle did not properly fit a very young child and they had to call for the assistance of a second crew.

During the course of the evidence it became apparent that there were only a few members of staff at the Nursery who had undergone Paediatric First Aid training, and that there is a need for specialist training when confronted with certain medical conditions affecting very young children. Other members of staff had general First Aid training but this appears to have been less useful in the circumstances.
It also transpired that the First Aid certification of some of the staff had lapsed by the passage of time, so that although they had undergone the training it now needed updating.

The EMD (call-taker) for the Ambulance Trust is a non-medically trained person who simply takes the details and reads from the appropriate “card” as to what questions should be asked and what advice should be given as well as determining how the case is to be triaged and allocated. It appears that because of a misinterpretation by that person as to the question of “ineffective/effective breathing”, the case was wrongly allocated.

I took the view that ALL nursery staff should be subject to mandatory paediatric First Aid training; that there should be better selection and training of Call-Takers for the ambulance service; that ALL emergency ambulances (including rapid response vehicles) should be equipped with suitable paediatric life-saving kit.