THE PARAMEDIC who treated schoolgirl Lilly-May Page-Bowden when she collapsed from a cardiac arrest in 2014 was today deemed to have committed ‘gross failure’ in her delivery of medical treatment, and inquest has heard.
Lilly-May, five, died on May 15, 2014 after collapsing as she was collected from Willow Bank School, in Woodley, by her mother Claire Page and her grandmother.
The child had suffered a cardiac arrest brought on by an undiagnosed condition known as catecholaminergic polymorphic ventricular tachycardia (CPVT), a genetic heart rhythm disturbance.
A resumed inquest into her death on Friday, following an initial two-day long hearing in November, concluded that the South Central Ambulance Service (SCAS) paramedic who first attended Lilly-May, Shannon Jacobs, had not acted according to the guidelines she had been taught when treating a peadiatric cardiac arrest patient.
Ms Jacobs had maintained that her understanding of the heart rhythm which Lilly-May was presenting on the day of her collapse, a fine ventricular fibrillation, would not have responded to a shock from a defibrillator, but the coroner Peter Bedford concluded that she was wrong.
‘Neglect’
Upon hearing evidence from Mark Catterall, a Principle Lecturer in Paramedic Practice at Oxford Brookes University where Ms Jacobs had studied in 2011, Mr Bedford deemed that Ms Jacobs had been taught correctly, and that the course followed all the necessary guidelines set by the UK Resuscitation Council.
He concluded that Lilly-May died of natural causes but her death had been contributed by neglect.
Mr Bedford said: “I believe there were missed opportunities to save Lilly-May’s life.
“We have heard evidence from independent consultants who agree that the first 15 minutes after initial collapse are crucial when treating a patient in cardiac arrest.
“We can see that the first paramedic team to respond, headed by Ms Jacobs, arrived on the scene within seven minutes, but the decision to not switch on the defibrillator in the ambulance, to not take the equipment to her, and ultimately not to deliver a shock, wasted valuable time.
“We have heard that when the air ambulance arrived seven minutes after the ambulance, and the HEMS doctor, Dr Slabbert, agreed with Ms Jacob’s decision not to shock, it was already too late for Lilly-May.
“What I do believe is that had Lilly-May been given a shock at the earliest opportunity, it would have saved her life.”
‘This should never have happened’
The child’s devastated family hugged and tried to console one another in court, before delivering a statement via their lawyer.
The statement read: “We are pleased this is now over.
“Lilly-May died far too early and we were looking for answers as to how this happened.
“It is now clear that Lilly-May suffered a ventricular fibrillation cardiac arrest on 15th May 2014. We have learnt that she had a genetic mutation gave rise to a condition called CPVT.
“We are concerned that a paramedic was unable to properly understand nationally recognised resuscitation protocols for the treatment of cardiac arrest in children.
“The paramedic failed to recognise that Lilly-May had a shockable rhythm and failed to deliver appropriate treatment with a defibrillator.
“We now also know that had Lilly-May been defibrillated within 15 minutes of her collapse she would have survived, and would still be with us.
“We have heard that changes have been put into effect at South Central Ambulance Service NHS Foundation Trust regarding defibrillation in children.
“However, this should never have happened in the first place.
“The Coroner has found that Lilly-May’s death was contributed to by neglect on the part of South Central Ambulance Service, and we hope that everyone involved in this inquest will have learnt from these events and that a child will not die again in the future for want of a defibrillator.”
SCAS has apologised to Lilly-May’s family. Read their statement here.
