1 Sep 2017 Mohammad Ismaeel Ashraf · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 6 Unsafe and unreliable lanyard identification of children’s food allergies View source Delays in issuing care plans for children with allergies View source Lack of a process for immediately communicating safety recommendations to affected parties View source Failure to provide issued care plans to the food provider View source Lack of care plans for all pupils who require them View source Inaccurate care plans View source See 3 more concerns
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 6
Action
Conduct routine half-term checks comparing displayed and catering-held Health Care Plans with the central master list.
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Action
Review and rectify Health Care Plan inaccuracies, update medical records, and provide signed, dated plans to catering staff.
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Action
Require written, signed medical notifications, promptly refer them to the SENCO and school nurse, and record notification handling.
View source
Action
Establish a Central Medical Register tracking Health Care Plans, medication, medicine locations, outstanding issues, and incomplete actions.
View source
Action
Request parental updates on pupils’ medical conditions once each term in addition to annual updates.
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Action
Implement allergy lunchtime controls requiring daily pre-orders, allergy-specific meal preparation, staff-supervised collection, and documented communication of allergy information.
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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.
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× 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 The Olive School, Small Heath; 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 The Olive School, Small Heath; 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 The Olive School, Small Heath; 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 The Olive School, Small Heath; 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 The Olive School, Small Heath; 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 The Olive School, Small Heath; 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
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct routine half-term checks comparing displayed and catering-held Health Care Plans with the central master list.
Verbatim wording from the response “The School has implemented a routine half termly check of all Health Care Plans displayed at key locations and held by the catering teams, which are cross checked against the master list held centrally at the school.” Source location 2017-0243-Response-by-Al-Hijrah-School
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and rectify Health Care Plan inaccuracies, update medical records, and provide signed, dated plans to catering staff.
Verbatim wording from the response “The School was very concerned to hear the evidence given by the uncle of the deceased at the inquest that the Health Care Plan for Ismael’s sister was inaccurate. At the time of the inquest the pupils were on the six week summer holiday and so neither pupil nor any other pupils were being put at risk at the time the evidence came to light. The School took immediate steps, before the school re-opened in September 2017, to review and rectify any inaccuracies.” Source location 2017-0243-Response-by-Al-Hijrah-School
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require written, signed medical notifications, promptly refer them to the SENCO and school nurse, and record notification handling.
Verbatim wording from the response “All notifications made to the School regarding a pupil’s medical condition, including allergies, must be provided by the parent/guardian to the School in writing using the data information sheet. The data information sheet must be signed by a parent/guardian of the pupil and counter signed by the staff member at the School accepting the document. The notification ensures that an accurate record is made of a pupil’s medical condition before a referral is made to the Birmingham Health Care Trust, who will issue a Health Care Plan if required.” Source location 2017-0243-Response-by-Al-Hijrah-School
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a Central Medical Register tracking Health Care Plans, medication, medicine locations, outstanding issues, and incomplete actions.
Verbatim wording from the response “The School has established a Central Medical Register which provides instant access to the status of a pupil’s Care Plan, all medication issued to a pupil and the location of the medicine. The Central Medical Register provides instant information to highlight any outstanding issues and the actions that are yet to be completed, including receipt of the Health Care Plan.” Source location 2017-0243-Response-by-Al-Hijrah-School
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request parental updates on pupils’ medical conditions once each term in addition to annual updates.
Verbatim wording from the response “The School will continue with its policy, as it has for many years, to send the existing medical details (including allergy details), out to every parent at the end of the school year. The information is sent to the parents for them to check and report back any changes at the start of the new academic year. The School now requests parental updates once a term in addition to the annual requests.” Source location 2017-0243-Response-by-Al-Hijrah-School
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement allergy lunchtime controls requiring daily pre-orders, allergy-specific meal preparation, staff-supervised collection, and documented communication of allergy information.
Verbatim wording from the response “Aside from the monthly meetings the School has implemented a robust system to ensure that the catering staff are notified of any new allergy information as soon as the School is notified. The pupil is added to the pre-order list and a prepared lunch is provided to the pupil by the catering team. The pupil is accompanied to lunch by a member of staff. A record is kept of all notifications made to the catering team. The pupil is issued once a Health Care Plan has been issued by the School, which is signed by both the catering manager and a signed record kept of delivery and receipt of the Health Care Plan to the catering manager.” Source location 2017-0243-Response-by-Al-Hijrah-School
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The School does not issue Health Care Plans; responsibility for issuing them rests with the Trust’s school nurse.
Verbatim wording from the response “The School is not responsible for issuing a pupil’s Health Care Plan. The School nurse employed by the Trust is the person responsible for issuing the Health Care Plans. The School immediately informs the School nurse of the pupil’s medical condition. The School nurse will then issue the pupil’s Health Care Plan, within seven days. It is not” Source location 2017-0243-Response-by-Al-Hijrah-School
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations