School criticised for failing to carry out CPR on bullied teenager who died by suicide in school bathroom
The school where a 16-year-old girl was found hanged in the toilets 90 minutes after going missing from a lesson has been criticised for failing to carry out CPR when she was found and for issues with the 999 call.
Dagmara Przybysz (16) an aspiring photographer, died at Pool Academy, Pool, Cornwall on May 17, 2016 after telling a classmate she was going to the toilet and not turning up to her science class.
At an inquest into the teenager's death, her parents asked why nobody from the school was looking for her in the 90 minutes between when she went missing and when she was found, while staff from South Western Ambulance Service questioned why staff did not carry out CPR despite being told to by a 999 call handler.
Cornwall Coroner's Court, sitting in Truro, heard CCTV showed Dagmara entering the toilets at 12.14.
Two young pupils aged 11 or 12 raised the alarm after using the facilities twice and realising Dagmara was still in there the second time.
They spoke to staff co-coordinator Paula Hosking who entered the toilets at at 13.50 and after calling for help from colleagues found Dagmara in the end cubicle.
Paramedics entered the toilets at 14.09 but Dagmara could not be saved.
Paramedic Christopher Taylor said they found Dagmara on the floor covered from head to toe in a blanket, with no evidence of any attempt at CPR, he said, adding that she was warm to touch.
He said paramedics carried out advanced life support on Dagmara for 20 minutes before deciding to stop after there was no response.
He said: "My concern is that we would have expected to find a defibrillator on the scene and some attempt (at CPR) made ... we were told 'no, there was no CPR'."
However he said he did not think the outcome would have been different if CPR had been attempted "on this occasion".
Christopher Rogers, who works for South Western Ambulance Service as the named safeguarding professional, said he met with Mr Taylor and the ambulance crews at the hospital and was made aware that no CPR had been carried out by school staff.
He said his "expectation" was the school would have undertaken CPR and said: "I felt there were some lessons that could be learned."
Mr Rogers said basic information was not given by the original caller to the 999 call handlers and that the caller was not with Dagmara while making the call, which was made from a cordless phone that crackled when the caller walked with it.
He said it was "always better if someone with the patient can ring 999" and explained that information given in that call determined the level of priority given to the call and determined whether a blue-light ambulance was sent.
Mr Rogers said he wrote a guide for making 999 calls following the incident which he distributed to all of the schools in Cornwall and has since visited Pool Academy to talk to staff.
Dagmara's parents Ewelina and Jedrzej, who do not have legal representation at the hearing, asked a series of questions about why nobody was looking for their daughter and why they had only been told today that a second girl had been missing at the same time as Dagmara.
Mr Przybysz said: "One year (on) and this is the first time we have heard anything like this ... I am not 100 per cent sure that this is true now because it is one year and nobody said anything."
Rodney Peasley, a member of the pastoral support staff, said he went to the toilets after hearing a call on the staff radio for first aiders.
Mr Peasley, who became emotional while giving evidence, described removing Dagmara from the cubicle and said she was "ice cold to the touch" and all her extremities were blue.
He said: "Someone communicated a message from the paramedics and said we should try resuscitation. I knew there was no point.
"I could not bring myself to do this. If I thought there was any hope of this working, I would have done it but I knew there was not any hope."
Mr Peasley said he had been a trained first aider for 20 years and had dealt with a fatality before.
Assistant principal Lisette Neesham said school guidelines meant a child should be found within 20 minutes and if not a decision would be taken on whether to refer the matter to the police.
Ms Neesham said she had "no evidence" to show Dagmara was looked for on May 17, 2016 but it was her understanding Dagmara was looked for "because a student clearly states it".
In relation to questions about why CPR was not carried out, Ms Neesham said she and another senior member of staff had instructed Mr Peasley to carry out CPR and he appeared to have agreed.
Dr Carlyon asked what areas the Academy had fallen below the level of expected care for Dagmara and Ms Neesham said: "I would have expected her to have been located in 20 minutes and if not an escalation (should have occurred)."
She added that CPR was not carried out as requested.
The inquest before Coroner Dr Emma Carlyon heard Dagmara had been having trouble with some girls at school and had previously told her parents and boyfriend that she had overheard classmates making racist comments, the inquest heard.
Mrs Przybysz said she understood her daughter had been having a problem with one girl who had "called Dagmara names".
"I don't know exactly what was said," she said. "This incident occurred only a few days before Dagmara passed away ... I don't know whether these incidents were racist in nature; however, I can say that on several occasions she overheard comments such as 'stupid Pole'."
She added that she felt Dagmara's biggest problem was bullying, not racism.
The inquest continues.