An inquest jury has concluded that a five-year-old boy who tragically died after an allergic reaction at school was accidentally exposed to cow's milk protein, most likely from his own bottle.
Benedict Blythe, a reception pupil at Barnack Primary School in Stamford, Lincolnshire, suffered food-induced anaphylaxis and died in hospital on 1 December 2021.
Jurors heard that the boy, who had joined the high-IQ society Mensa at the age of four, was asthmatic and had severe allergies to milk, eggs, and certain nuts. He had vomited twice before going into cardiac arrest.
On Wednesday, the foreperson of the jury at Peterborough Town Hall said: “We deem the probable source of the allergen that caused the fatal anaphylaxis is the ingestion of cow’s milk protein, most probably from his own receptacle during break time.”
Speaking after the conclusion of the inquest, Benedict’s mother Helen Blythe said: “Benedict died in a place where he should have been safe – his school.
“Benedict’s death was preventable and was caused by a cascade of failures – individual, institutional, and systemic.”
Factors which the jury found “probably caused” Benedict’s death include the delayed administration of his adrenaline, opportunities for cross-contamination or mix up of milk, and that his allergy plan was not shared with teaching staff.
Jurors recorded the conclusion as “accidental exposure to an allergen, cow’s milk protein, causing fatal anaphylaxis”.
The jury also found Benedict’s recent illness, exercise, his uncontrolled asthma, and a “missed opportunity” to review “lessons learned” after he had an allergic reaction to pizza at school in the October before his death were other factors.
Benedict was kept home from school the day before he died because he had been unwell and vomited, but woke up “in good health” the next morning.
The eight-day inquest heard that he ate a McVitie’s gingerbread biscuit during break time that morning, which he had eaten on previous occasions, and refused to drink a bottle of oat milk poured by his teacher.
The jury was told that a sample of the biscuit was independently tested for cow’s milk proteins, but traces were not detectable.
He also ate dairy-free chocolate before he went to school, which his parents had put into an advent calendar, and his usual breakfast cereal with oat milk.
Area coroner for Cambridgeshire and Peterborough Elizabeth Gray told the jury they “may not record” that the allergic reaction was a response to the biscuit, the chocolate, or his breakfast, based on the evidence heard.
Dr Shuaib Nasser, a consultant in asthma and allergy, concluded that a “small amount” of cow’s milk most likely caused the fatal anaphylactic reaction because Benedict had a “life-threatening” milk allergy, while his egg allergy was “mild”, the jury was told.
The inquest heard Benedict’s adrenaline auto-injector (AAI) was administered twice by a teaching assistant, before CPR and a defibrillator were attempted but he died later that day at Peterborough City Hospital.
The jury was told that Benedict’s oat milk, given to the school by his parents, was kept in a separate fridge in the staff room along with a carton of lactose-free milk for another child in his class.
The class teacher, Jenny Brass, told the inquest she would not have confused Benedict’s oat milk with the lactose-free milk, which he could not drink because it contained dairy allergens.
The jury concluded that the school’s usual procedure of giving Benedict his milk was not followed on the day of his death because the milk was poured into his cup in the staff room rather than in the classroom and given “directly” to him.
Benedict’s mother said the school was given a management plan for his allergic reactions, and said vomiting was “always” the first symptom.
The jury heard that Benedict loved school, was “extremely bright” and was “thriving” in the three months he spent there before his death.
The Benedict Blythe Foundation was set up in the schoolboy’s memory and, along with The Allergy Team and the Independent Schools’ Bursars Association (ISBA), launched the schools allergy code last year to set out how schools can keep pupils safe.
Speaking outside Peterborough Town Hall after the conclusion of the inquest, Ms Blythe said: “There were critical failings from the very beginning.
“The investigation at the time was inadequate as the evidence needed to establish how and why he died was never obtained. Because of that, precious time was lost — and with it, opportunities to understand what happened to our son.
“No more children should die at school because of an allergy.
“We demand change. We call on this government to protect our children with Benedict’s Law, making it mandatory to have an allergy policy in every school, staff allergy training including understanding allergies, how to manage them and identify signs of a reaction, and respond quickly in an emergency, and spare adrenaline allergy pens in every school.
“Proper oversight. Real accountability. Immediate action. We owe that to every child.”
