On the 24th February 2017 the HM Senior Coroner for Berkshire concluded the inquest into the death of Lilly-May Page Bowden who died on the 15th May 2014. At the time of her death Lilly-May was 5 years old. She had just finished for the day at her school and was running across the school playground when she collapsed. Two mothers at the school who were qualified nurses went to Lilly-May and quickly established that she had suffered a cardiac arrest. They immediately instituted cardiopulmonary resuscitation and a 999 call was made.
The 1st ambulance arrived within 8 minutes. However, the paramedic decided to go to Lilly-May without any equipment and to carry her back to the ambulance. An expert witness concluded that such a decision could only be reasonable if the other crew member had prepared the equipment within the ambulance and switched on the defibrillator. Those steps were not undertaken.
It became apparent in evidence that there was at least a 2 ½ minute delay in switching on the defibrillator and then further delay in determining the nature of the cardiac rhythm. Expert evidence was provided which indicated that those delays were not only serious but also resulted (on a balance of probabilities) in the death of Lilly-May.
An expert witness in Paediatric Cardiology told the inquest that Lilly-May had an anatomically normal heart and that her death was subsequently found to as a result of CPVT (catecholaminergic polymorphic ventricular tachycardia). Had a defibrillator been used to provide a shock within 15 minutes of the collapse then on a balance of probabilities Lilly-May would have survived and her underlying condition was treatable.
The paramedic stated in her evidence that she found the rhythm to be “fine ventricular fibrillation”. She also stated that she had been taught during her training (at Oxford Brookes University) that she should not defibrillate fine ventricular fibrillation in children; rather they should be managed with cardiopulmonary resuscitation and observed to see if the rhythm changed to course ventricular fibrillation.
All expert and paramedic evidence was to the effect that there was no support for such a proposition. The Resuscitation Council of the United Kingdom and Joint Royal Colleges Ambulance Liaison Committee had not provided such guidance at the material time and that the rhythm demonstrated at the material time should have been treated with a shock.
Further the understanding of the paramedic was at complete variance with the Paediatric Advanced Life Support Algorhythm in operation at the material time.
The inquest was adjourned to hear evidence from Oxford Brookes University regarding the course that the paramedic had attended (a 2 year degree course). The principal lecturer confirmed that none of the evidence provided by the paramedic conformed with that which was taught and confirmed that such could not be the case for the reasons set out above.
The HM Coroner concluded that while Lilly-May had suffered death as a result of natural causes; the care that had been provided was such that it amounted to a gross failure to provide basic care. He noted that there could be no more basic care that the provision of defibrillation in a cardiac arrest.
Furthermore, there was a causal link between those failures and the death of Lilly-May.
1. The test for neglect in the setting of an inquest is set out within the case of R v North Humberside Coroner Ex p Jamieson  QB 1 CA (see also 13-91 Jervis on Coroners 13th Edition);
“Neglect in this context means a gross failure to provide adequate nourishment or liquid, or provide or procure basic medical attention or shelter or warmth for someone in a dependent position (because of youth, age, illness or incarceration) who cannot provide it for himself. Failure to provide medical attention for a dependent person whose physical condition is such as to show that he obviously needs it may amount to neglect. So it may be if it is the dependent person’s mental condition which obviously calls for medical attention…In both cases the crucial consideration will be what the dependent person’s condition, whether physical or mental, appears to be.”
The Coroner must be satisfied that the actions or omissions were such that they amounted to a significant departure from the care that would be reasonably delivered. It is not sufficient that the care was misguided.
It was submitted that in this case the departure from nationally approved and validated resuscitation guidelines as issued by the United Kingdom Resuscitation Council did amount to a significant departure and on any construction it must have amounted to “gross failure”.
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