UK Inquiry Tracker

Esmee Polmear

PFD Report Historic (No Identified Response) Ref: 2016-0203

Date of Report 27 May 2016

Coroner Elizabeth Carlyon

Coroner Area Cornwall

Response Deadline est. 22 July 2016

Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

Failure to routinely use respiratory rate benchmarks, oxygen blood monitoring, and recognise critical red markers in paediatric respiratory medicine hindered diagnosis and treatment.

View full coroner's concerns

_ At the inquest Ihe Paediatric Expert, Igave the opinion (hat The routine use of respiratory rate bench-markers in paediatric respiratory medicine The use of rouline oxygen blood monitoring in paediatric medicine The recognition and action on red markers (which in this case were shortness of breath, chest pain and blue lips) Would have assisted and improved the chances of diagnosis and treatment of Esmee and other children,wilh a view to preventing_future deaths or providing day flag appropriate treatment and palliative care in life limiting cases

Sent To

Kernow Clinical Commissioning Group
NHS England

Response Status

Linked responses 0 of 2

56-Day Deadline 22 Jul 2016

About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections

Investigation and Inquest

Esmee Polmear died on 1st July 2015 and an investigation commenced on 15th July and an inquest was opened on 20th October 2015 A full hearing was held on 13th April 2016

Circumstances of the Death

Esmee Polmear (DoB 13.03.08) felt ill whilst going on a school trip from her Primary School in Perranporth; to Perranporth Beach on the morning of the 18t July 2015. On her return she collapsed and went into cardiac arrest; Paramedics attended and she was transferred to the Royal Cornwall Hospital where despite attempts at resuscitation she was recognised dead: She died from Pulmonary veno-occlusive disease which is a rare life limiting condition: She had been under the investigation of her GP and the Royal Cornwall Hospital, Paediatric services in the months prior to her death but her condition was not diagnosed or recognised prior to death:

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to lake such action: And that you are undertaking your own reviews and investigations into this death with a view to Local and Nationwide learning: In order to assist (with the consent RCHT and St Agnes Surgery) attach St Agnes surgery root cause analysis incident no 2015#24302 Royal Cornwall Hospital, Treliske, Truro Serious Incident Report 2015/24302