Coroner rules neglect contributed to the death of 15-year-old Zara Cheesman after failings by healthcare professionals

A Prevention of Future deaths order has now been issued in respect of East Midlands Ambulance Service NHS Trust (EMAS)

The inquest into the death of teenager Zara Alice Cheesman has concluded that her death was avoidable and contributed to by neglect after failings by ambulance services.

Assistant Coroner Dr Elizabeth Didcock ruled that Zara died from bacterial meningitis, following missed opportunities by healthcare professionals and gross failings by EMAS to carry out an adequate assessment and provide a basic level of care.

The three-day inquest at Nottingham Coroner’s Court concluded on Wednesday, 17 September 2025. It found that basic failings in clinical judgment and escalation protocols by several members of staff at Nottingham University Hospitals Trust and East Midlands Ambulance Service contributed to her death. Zara, of Mapperley Park, Nottingham, died on 23 December 2024.

The inquest heard that “incredibly kind” Zara had a love of literature, music and drama from a young age. Zara’s parents, Judith and Mark, and her brother, Alec, described how, after dabbling in many sports, she uncovered a talent for sprinting and wanted to return to athletics and football. Zara cared deeply about the problems in the world, driven by her staunch feminist beliefs, and intended to become a human rights lawyer.

Zara first became unwell on 19 December 2024 after returning home from school, experiencing vomiting, aching limbs, and pain in her neck and shoulders. The following day, her parents contacted 111 and took her to A&E, where she was triaged and seen in the teenagers’ section.

Evidence given at the inquest revealed how an advanced nurse practitioner raised concerns about possible meningitis and recommended blood tests. However, the specialist registrar on call decided not to carry out the tests and discharged Zara home.

Zara’s condition worsened overnight and into the next morning. On 21 December 2024 and following another call to 111, an ambulance was sent to her home where she was seen by an ambulance technician and a trainee technician. Despite her parents reporting worsening symptoms, the paramedics advised rest and fluids and did not escalate her care or transfer her to hospital, regardless of EMAS’s own guidance.

Zara continued to deteriorate and appeared to lose consciousness overnight. Her parents called 999 and an ambulance arrived to find Zara in respiratory failure. It was later confirmed in hospital that she had died of bacterial meningitis.

The inquest concluded that there were gross failings by EMAS healthcare professionals in assessing Zara and failing to admit her to hospital. The coroner confirmed that this amounted to neglect and said she wasn’t “confident” that this wouldn’t happen again without urgent review. She therefore issued a Prevention of Future Deaths order in respect of EMAS.

Zara’s family is represented by law firm Freeths’ Clinical Negligence team, with Managing Associate Gemma Bedford leading on the case, supported by Senior Associate Katy Walton.

In a statement following the conclusion, Zara’s family said: “Losing Zara has left a hole in our lives that can never be filled. She was empathetic, funny, intelligent and full of promise - a daughter, a sister, and a friend whose laughter lit up every room."

"The inquest has confirmed what we have long feared: Zara’s death was preventable and we’re devastated that Zara’s life was taken unjustly from us due to the neglect of basic care and treatment by medical professionals. We urge families to be aware of the symptoms of meningitis and to speak to their GP about vaccination options. Zara had all the NHS recommended vaccinations including the teenage meningitis vaccines. However, she died of meningitis B, which was not covered by these vaccines. The vaccine for meningitis B was only available from 2015 to children under two. For those of Zara’s age group (born before 2013) and above the vaccine is only available through private providers."

"Our deepest wish is that lessons are learned, and actions are taken so that no other family must go through what we have. We will continue to honour her by advocating for change and fighting for justice for Zara.”

Representing the family, Gemma Bedford, Managing Associate at Freeths, said: “We are grateful to the coroner for carrying out a thorough investigation into the tragic circumstances surrounding Zara’s death - a loss that any family would find incredibly difficult to come to terms with."

"The family welcome the Prevention of Future Deaths order and sincerely hopes that action is urgently taken to ensure lessons are learned. They hope that meaningful changes will be made to prevent other families from experiencing such a needless tragedy."

"It is concerning that despite Zara being seen on two occasions, her meningitis was not diagnosed or treated in adequate time. In particular, the inadequacy of the assessment carried out by the EMAS technicians led to a failure to convey Zara to hospital, which on balance led to her death. The treatment for meningitis is well known and established, and we are continuing to support the family in seeking answers as to why this care was not provided."

"The courage and fortitude shown by Zara’s family members in sharing their story has been remarkable. They will now need time to grieve and begin to come to terms with their loss, and they hope that the outcome of this inquest will lead to real change so that no other family must endure what they have.”

Dr Tom Nutt, Chief Executive of Meningitis Now, added: “The death of 15-year-old Zara Cheesman is a tragedy, and our thoughts today are with Zara’s parents and her family."

"Sadly, cases of missed or delayed diagnosis are something we see all too often at Meningitis Now. It is true that spotting the early signs and symptoms of meningitis can be difficult, but it is also clear that timely diagnosis can make the difference between life and death.”

"We have to hope that lessons can be learned from this case. This means that clinicians have to listen better to the concerns of parents and even of their own colleagues when faced with an unwell and deteriorating patient. This is why the recent introduction of Martha’s Rule is so important, giving patients, carers and even clinical staff the chance to be heard and to have their care reviewed."

"It’s vital that people are aware of the signs and symptoms of meningitis and seek urgent medical help if they or someone else are unwell. We would also encourage everyone to ensure their vaccinations are up to date, no matter what age, as these can help prevent many cases of the disease."