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Five-year-old girl would probably have been saved if she was shocked at 'earliest opportunity', coroner concludes

Swift action to defibrillate a five-year-old from Ruscombe would probably have saved her life, a coroner concluded today.

Peter Bedford concluded Lilly May Page-Bowden, of Pennfields Drive, would have survived had she been shocked with a defibrillator within 15 minutes of her collapse and said 'neglect' contributed to her death.

Lilly May collapsed at Willow Bank Infant School, Woodley, on Thursday, May 15, 2014 and died the same day.

The inquest, which resumed after an adjournment of nearly three months, had heard in November how a paramedic for South Central Ambulance Service, Shannon Jacobs, arrived at the scene at 3.24pm that day as Lilly May received CPR from a bystander, a nurse.

Ms Jacobs took Lilly May into her ambulance and read her heart rhythm on a monitor, which she decided showed a ‘very fine ventricular fibrillation (VF)’, a rhythm she believed was not shockable with a defibrillator.

Lilly May was taken to the Royal Berkshire Hospital in Reading, where her death was confirmed later that day.

Ms Jacobs had said she felt her training was not adequate enough for her job and that Lilly May had an undiagnosed heart condition.

As the inquest resumed today at Reading Town Hall, coroner Peter Bedford heard evidence from Matthew Catterall, a practioner at Oxford Brookes University where Ms Jacobs completed her training.

Mr Catteral stated it was unlikely for a student with Ms Jacobs' academic record, and hundreds of hours worth of practical experience and teaching time would not have had adequate training.

He said the subsequent need for continued professional development would contradict Ms Jacob's claims and he found no evidence during his investigation to substantiate what she said.

He added: "All the other students passed through the course without complaint, and I'm not aware of any other graduates being investigated for clinical errors."

In his conclusion, 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.

"What I do believe is that had Lilly May been given a shock at the earliest opportunity, it would probably have saved her life."

He concluded Lilly May died of natural causes but neglect had contributed to her death.


Speaking on behalf of Lilly's family outside the court, legal counsel Hayley Eames said: "Lilly May died far too early and we were looking for answer as to why this happened.

"It is now clear that Lilly May suffered ventricular fibrillation.

"We have learned that she had a genetic mutation that gave rise to a condition, CPVT.

"We are concerned the paramedic was unable to properly understand nationally recognised resuscitation protocols for the treatment of cardiac arrest in children.

"We now also know that had Lilly May been defibrillated 15 minutes of her collapse she would have survived and she would be with us.

"We have heard that changes have been put into affect at SCAS NHS 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 behalf of SCAS and we hope that everyone involved in this inquest will have learnt from these events so that a child will not die again in the future."


In a statement released after the inquest, Deirdre Thompson, director of patient care at SCAS, said: “South Central Ambulance Service NHS Foundation Trust (SCAS) has previously offered its sincere condolences to Lilly-May’s family and I would like to reiterate those today as this inquest must have brought back many traumatic memories of the events of May 15, 2014.

"The Trust has undertaken a detailed investigation into our response to Lilly May’s death from sudden arrhythmic death (SADs) and shared these findings, and our subsequent actions, with Lilly May’s family.

"We accept the findings of the coroner today and offer our sincere apologies to Lilly May’s family.”

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