09:44PM, Tuesday 29 November 2016
An inquest into the death of a five-year-old girl from Ruscombe heard a paramedic felt her training was not adequate enough for her job.
The Berkshire Coroners Court, in Reading Town Hall, heard today how Shannon Jacobs, who had trained as a paramedic at Oxford Brookes University and was working as a paramedic for the South Central Ambulance Service, got called out to Willow Bank Infant School in Woodley on May 15, 2014.
There, five-year-old pupil Lilly May Page-Bowden, of Pennfields, had collapsed at about 3.15pm after playing with her friend.
The inquest heard her mum, Claire Page, had gone to pick her up but saw her through the crowd of pupils and parents, lying on her back, motionless.
She went to help, 999 was dialled and a bystander, who was a registered nurse, tried to help her.
The inquest was told Ms Jacobs arrived on the scene with her colleague, and took Lilly into the ambulance. She appeared pale with dilated pupils and was blue around the lips.
The inquest heard Ms Jacobs decided against shocking Lilly with a defibrillator due to her heart rhythm, which she believed from her training would cause more harm than good.
Ms Jacobs described the rhythm as ‘very fine ventricular fibrillation (VF)’, which she believed had been taught to her at Oxford Brookes University as a situation that is ‘unshockable’.
Just after 3.30pm, an air ambulance arrived with a doctor who took control and also decided the rhythm was ‘unshockable’.
Lilly was then taken to the Royal Berkshire Hospital where doctors were unable to revive her and she was pronounced dead.
A subsequent autopsy found she had suffered from sudden arrhythmic death.
An investigation into the death, launched by the South Central Ambulance Service, determined that a clinician believed Lilly could have been saved if she had been shocked by a defibrillator as early as possible, but could not conclude for sure that the outcome would have been different.
Ms Jacobs had been made aware of this by a consultant following the incident.
When questioned by the advocate for Lilly’s family, Ms Jacobs said her education might have hindered her ability as she had not practiced helping a child in cardiac arrest, and was told it was rare.
She said during her training, 'they said if it is fine VF to rely on CPR' and when the advocate suggested a nob on the monitor that displays the heart rhythm should be adjusted to display the rhythm larger or smaller to help assess it, she added: "We were not taught that as part of our training."
She trained at the Health and Care Professions Council-approved course at Oxford Brookes from 2009.
She has since been on core skill refresher courses.
The inquest heard how guidelines on paediatric cardiac arrest had changed since Ms Jacobs had been a student but there was no ‘literature’ that suggested a medical professional could not shock in such circumstances.
The inquest continues.
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