Zara Cheesman

“There is no detailed organisational understanding of the extent of the issues identified in this case - that of the very limited assessment of a child or young person, the reliance on the incorrect physiological scoring system used, and the non- conveyance decisions made.”

“There is insufficient audit and monitoring of EMAS operational staff by senior clinical staff, to ensure there is both understanding and following of key EMAS guidelines”

“There is insufficient continuing professional development for operational staff in respect of the assessment of sick children and young people, with frontline staff having limited knowledge and understanding of the Children and Young Persons clinical guideline (that includes the importance of listening to parents, physiological scoring systems in children, and the significance of a change in mental state of a child or young person)”