Recipient

Cater Link Limited

First report 1 Sep 2017•Latest report 1 Sep 2017

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Private limited company. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Cater Link Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

1 Sep2017
Birmingham and Solihull
Concerns raised6
1. Unsafe and unreliable lanyard identification of children’s food allergies
2. Delays in issuing care plans for children with allergies
3. Lack of a process for immediately communicating safety recommendations to affected parties
1. Failure to provide issued care plans to the food provider
2. Lack of care plans for all pupils who require them
3. Inaccurate care plans
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Mohammad Ismaeel Ashraf · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mohammad Ismaeel Ashraf, a nine-year-old boy with multiple food allergies, suffered an anaphylactic reaction at school after eating lunch and died later that day following unsuccessful resuscitation. Concerns included failures and delays in care plans, ineffective communication about allergy information, unsafe allergy-identification lanyards, and failure to administer his epipen promptly despite his deteriorating condition.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cater Link Limited; that does not assign responsibility.
PFD Monitor interpretation
Unsafe and unreliable lanyard identification of children’s food allergies
Wider context from the report
“4. As an interim measure lanyards had been used to try and identify which food children were allergic to when buying their lunch. The Inquest heard how some lanyards were not accurate and lanyards themselves are not as safe as they may be amended or worn by a different pupil. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cater Link Limited; that does not assign responsibility.
PFD Monitor interpretation
Delays in issuing care plans for children with allergies
Wider context from the report
“2. That there are delays in issuing care plans. Care plans need to be issued quickly where a child has an allergy. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cater Link Limited; that does not assign responsibility.
PFD Monitor interpretation
Lack of a process for immediately communicating safety recommendations to affected parties
Wider context from the report
“5. Immediately following this tragic event, the Local Authority procured a report to look at the safety of food delivery in the school. That report identified a number of matters requiring attention which included identifying that the lanyard system that the school had introduced as an interim measure was not safe. This recommendation and others were not communicated to the school or anyone else, to enable them to make essential changes to processes to ensure the management of children with food allergies was adequate. I am therefore concerned that the local authority has no process in place to ensure that recommendations are immediately communicated to those affected by them so that practices can be changed and processes put in place to rectify the problem. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cater Link Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide issued care plans to the food provider
Wider context from the report
“3. All issued care plans had not been provided to Caterlink by the school and communication between the school and Caterlink was not as effective as they could be. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cater Link Limited; that does not assign responsibility.
PFD Monitor interpretation
Lack of care plans for all pupils who require them
Wider context from the report
“1. That care plans are not in place for all pupils that require them. Evidence was heard at the Inquest that the deceased’s sister’s care plan is still inaccurate, despite this having been identified to the school. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cater Link Limited; that does not assign responsibility.
PFD Monitor interpretation
Inaccurate care plans
Wider context from the report
“1. That care plans are not in place for all pupils that require them. Evidence was heard at the Inquest that the deceased’s sister’s care plan is still inaccurate, despite this having been identified to the school. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised6

Unsafe and unreliable lanyard identification of children’s food allergies

Delays in issuing care plans for children with allergies

Lack of a process for immediately communicating safety recommendations to affected parties

Failure to provide issued care plans to the food provider

Lack of care plans for all pupils who require them

Inaccurate care plans