Zara Alice Cheesman · Prevention of Future Deaths report

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 advise 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 irreversible. 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

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 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.

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.