The mother of a boy who died from an allergic reaction to his school dinner has accused staff who failed to give him a potentially life-saving shot of adrenaline of failing in their duty of care.
Nasar Ahmed, 14, went into anaphylactic shock while in detention at Bow school in east London last November after suffering a reaction to milk in his tandoori chicken lunch. He had a history of severe asthma and food allergies, but staff did not administer his EpiPen, which was kept at school and could have saved him.
Instead the school called an ambulance and he was taken to the Royal London hospital, where he died four days later.
On Friday morning after the conclusion of the inquest into her son’s death, Ferdousi Zaman told reporters outside Poplar coroner’s court: “If he has anaphylaxis I give him his EpiPen. They are first-aiders, they are more knowledgeable than me.
“They have failed their duty of care.”
Coroner Mary Hassell on Friday returned a narrative conclusion, saying: “The staff saw Nasar’s EpiPen and considered using it, but did not.
“If the EpiPen had been used promptly and Nasar had been administered adrenaline, there is a possibility but not a probability that this would have changed the outcome.”
Hassell said she would be writing prevention of future death (PFD) reports to Nasar’s school, his GP, Barts Health NHS Trust and the London ambulance service, whose paramedic told staff over the phone not to give Nasar adrenaline before they arrived.
Outlining her PFD to the ambulance service, she said: “The paramedic said don’t give the EpiPen because there were no classic symptoms of anaphylaxis. The reality of giving a dose of adrenaline is that it is unlikely to do any significant harm, whereas the potential good of giving an EpiPen is lifesaving.”
The coroner is also sending a PFD report to the chief medical officer for England, asking whether EpiPens should be widely provided alongside defibrillators in public places.
Nasar, a year 9 pupil, was in the internal exclusion room (IER) at the school when he complained of breathing problems then collapsed at 2.21pm on 10 November. He was put on oxygen as soon as he arrived at the Royal London, but a brain scan showed he was unresponsive. He died on 14 November.
The inquest heard that Nasar’s asthma had been inaccurately listed by the school nurse in his care plan as “mild to moderate” rather than “severe” and there was no mention of an EpiPen or using adrenaline to tackle his allergies, although the school kept two of the devices on site in case he showed symptoms.
In her determination, Hassell said: “Staff at the school were encouraged to familiarise themselves with pupils’ care plans but often did not unless there was a school excursion.
“Even the deputy head teacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact he had a care plan and allergy action plan when he made the decision to place Nasar in the IER.
“Knowledge of the care plan would not have changed the decision ... but the lack of familiarity of the IER supervisor and nearby members of staff with Nasar’s allergy action plan and medication box used up time in an extremely time-critical situation.”
In a statement, Bow school’s executive headteacher, Cath Smith, said: “We are all deeply saddened about this tragic incident and continue to offer our heartfelt sympathies to Nasar’s family.
“The safety of those in our care is, of course, our overriding concern, and following Nasar’s death we rigorously reviewed all of our safety procedures and are providing more training for staff across the board.
“We will now consider the advice from the coroner very carefully to see what further action we should take.”
In a statement read by their solicitor Lochlinn Parker, the family added that they were “deeply saddened to now know of the missed opportunities to save Nasar’s life”.
“We strongly believe that if Nasar’s care plan had been completed correctly, if staff had been aware of the care plan and if it had been followed properly, including administering an EpiPen as soon as possible, that Nasar would be alive today.
“Following our painful loss of Nasar we hope that important lessons about the care of children suffering from asthma will be learnt and other lives saved.”
