The death of a nine-year-old boy following an allergic reaction was partly down to neglect by his school, an inquest jury has found.
Mohammed Ismaeel Ashraf collapsed less than two hours after eating a lunch of fish fingers and chips at Al-Hijrah school in Bordesley Green, Birmingham, in March. He was taken to Heartlands hospital, where he later died.
Pathologists concluded that Mohammed died from an anaphylactic reaction, caused by an unknown allergen.
After a four-day hearing, an inquest jury concluded that neglect on the part of the school played a part in his death. Louise Hunt, the senior coroner for Birmingham and Solihull, said there were many problems with the way the school managed pupils with allergies and she would be writing to the local authority to highlight her concerns.
The coroner’s court was told that Mohammed was allergic to dairy and nuts, kiwi fruit and some fish, but he was served fish fingers regularly because canteen staff had not read his care plan.
However, doctors concluded that it was unlikely he had suffered a reaction to the food he ate in the school’s canteen, because he fell ill nearly two hours later. Severe allergic reactions to food usually develop within 30 minutes. The cause of his death was more likely to have been something he ate in the playground, the court heard.
Three doctors giving evidence agreed that the delay in administering an adrenaline injection might have contributed to his death, but not caused it. Giving evidence to the inquest, his class teacher, Shaid Yousef, admitted there had been a delay in giving Mohammed his EpiPen because he had not grasped the seriousness of the allergic reaction.
Hunt said she would be writing a report to prevent future deaths and sending it to the chief coroner and local health authority. Despite Mohammed’s death, she said, care plans were still not in place for all pupils at the school with health needs, including his sister.
“Not all the care plans which have been drawn up have been given to the catering company responsible for dishing up all meals,” Hunt said. “Lanyards meant to be worn round the necks of children with food allergies are not being worn properly.”
The school, which is in special measures and being run by Birmingham city council, said it has tightened up procedures, making staff more aware of pupils’ care plans and fixing medical boxes containing EpiPens to the front walls of every classroom.
