PFD report

Nasar AHMED · Prevention of Future Deaths report

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Issued 12 May 2017•Inner North London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
13

Raised in this report

Recipients
8

Named on the report

Responses found
7

Of 8 recipients

Stated actions
59

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised13

  1. Insufficient first-aid training for staff supervising pupils
    Part of recurring concern: Inadequate staff competence to provide first aid
  2. Failure to confirm replacement medication and complete its dose in the action plan
    Part of recurring concern: Unreliable medication reconciliation across care transitions
  3. Provision of inappropriate emergency asthma inhalers without spacers
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.42

  1. Action

    Promote personalised written emergency plans for anaphylaxis and provide adaptable templates for healthcare professionals.

    Stated by The British Society For Allergy & Clinical ImmunologyStated completedThe respondent said that this action was complete when they made their response on 3 May 2023.
  2. Action

    Produce national allergy-management guidelines through a NICE-accredited process.

    Stated by The British Society For Allergy & Clinical ImmunologyStated completedThe respondent said that this action was complete when they made their response on 3 May 2023.
  3. Action

    Support a campaign securing regulatory changes allowing schools to obtain spare adrenaline auto-injectors without prescription for emergencies.

    Stated by The British Society For Allergy & Clinical ImmunologyStated completedThe respondent said that this action was complete when they made their response on 3 May 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.11

  1. Position

    An accuhaler was considered appropriate for the child's preventer treatment; guidance did not require an additional emergency metered-dose inhaler with spacer.

    Stated by The Bromley by Bow Health PartnershipDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Insufficient first-aid training for staff supervising pupils

Wider context from the report

“The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces. Is this a suggestion that could be given wider consideration? 1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious. However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving. 1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner. Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death. Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed? 2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration. I wonder whether there is a widespread lack of understanding of the best treatment in this situation? 3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records. 4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely? 1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy. 2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided. 3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER. 4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan. 5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan. 6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help? 7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay. 1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist. 2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting. 3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. 4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication. These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools. ”

Is this part of a recurring concern?

Yes — Inadequate staff competence to provide first aid.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to confirm replacement medication and complete its dose in the action plan

Wider context from the report

“The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces. Is this a suggestion that could be given wider consideration? 1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious. However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving. 1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner. Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death. Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed? 2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration. I wonder whether there is a widespread lack of understanding of the best treatment in this situation? 3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records. 4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely? 1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy. 2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided. 3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER. 4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan. 5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan. 6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help? 7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay. 1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist. 2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting. 3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. 4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication. These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools. ”

Is this part of a recurring concern?

Yes — Unreliable medication reconciliation across care transitions.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Provision of inappropriate emergency asthma inhalers without spacers

Wider context from the report

“The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces. Is this a suggestion that could be given wider consideration? 1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious. However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving. 1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner. Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death. Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed? 2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration. I wonder whether there is a widespread lack of understanding of the best treatment in this situation? 3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records. 4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely? 1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy. 2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided. 3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER. 4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan. 5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan. 6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help? 7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay. 1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist. 2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting. 3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. 4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication. These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to verify school medication directly during medication reviews

Wider context from the report

“The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces. Is this a suggestion that could be given wider consideration? 1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious. However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving. 1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner. Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death. Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed? 2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration. I wonder whether there is a widespread lack of understanding of the best treatment in this situation? 3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records. 4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely? 1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy. 2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided. 3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER. 4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan. 5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan. 6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help? 7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay. 1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist. 2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting. 3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. 4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication. These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools. ”

Is this part of a recurring concern?

Yes — Failure to reliably conduct clinically required medication reviews; Failure to reliably verify medication information during care assessments.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to provide and follow immediate adrenaline auto-injector administration guidance

Wider context from the report

“The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces. Is this a suggestion that could be given wider consideration? 1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious. However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving. 1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner. Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death. Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed? 2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration. I wonder whether there is a widespread lack of understanding of the best treatment in this situation? 3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records. 4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely? 1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy. 2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided. 3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER. 4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan. 5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan. 6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help? 7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay. 1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist. 2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting. 3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. 4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication. These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of school staff to familiarise themselves with pupils’ care plans

Wider context from the report

“The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces. Is this a suggestion that could be given wider consideration? 1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious. However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving. 1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner. Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death. Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed? 2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration. I wonder whether there is a widespread lack of understanding of the best treatment in this situation? 3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records. 4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely? 1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy. 2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided. 3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER. 4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan. 5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan. 6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help? 7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay. 1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist. 2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting. 3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. 4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication. These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools. ”

Is this part of a recurring concern?

Yes — Inadequate staff competence in care planning.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to identify poor asthma control and excessive inhaler prescribing for specialist review

Wider context from the report

“The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces. Is this a suggestion that could be given wider consideration? 1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious. However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving. 1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner. Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death. Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed? 2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration. I wonder whether there is a widespread lack of understanding of the best treatment in this situation? 3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records. 4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely? 1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy. 2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided. 3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER. 4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan. 5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan. 6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help? 7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay. 1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist. 2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting. 3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. 4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication. These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools. ”

Is this part of a recurring concern?

Yes — Unreliable asthma care and management.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to maintain accurate allergy action plans with medication-use instructions

Wider context from the report

“The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces. Is this a suggestion that could be given wider consideration? 1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious. However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving. 1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner. Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death. Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed? 2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration. I wonder whether there is a widespread lack of understanding of the best treatment in this situation? 3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records. 4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely? 1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy. 2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided. 3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER. 4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan. 5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan. 6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help? 7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay. 1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist. 2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting. 3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. 4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication. These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools. ”

Is this part of a recurring concern?

Yes — Unreliable care-planning processes.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to include a school representative in medication reviews

Wider context from the report

“The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces. Is this a suggestion that could be given wider consideration? 1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious. However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving. 1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner. Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death. Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed? 2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration. I wonder whether there is a widespread lack of understanding of the best treatment in this situation? 3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records. 4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely? 1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy. 2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided. 3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER. 4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan. 5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan. 6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help? 7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay. 1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist. 2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting. 3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. 4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication. These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to maintain identical current care-plan copies across care settings

Wider context from the report

“The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces. Is this a suggestion that could be given wider consideration? 1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious. However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving. 1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner. Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death. Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed? 2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration. I wonder whether there is a widespread lack of understanding of the best treatment in this situation? 3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records. 4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely? 1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy. 2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided. 3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER. 4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan. 5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan. 6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help? 7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay. 1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist. 2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting. 3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. 4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication. These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Emergency-services contact procedures causing avoidable delay

Wider context from the report

“The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces. Is this a suggestion that could be given wider consideration? 1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious. However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving. 1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner. Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death. Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed? 2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration. I wonder whether there is a widespread lack of understanding of the best treatment in this situation? 3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records. 4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely? 1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy. 2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided. 3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER. 4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan. 5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan. 6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help? 7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay. 1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist. 2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting. 3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. 4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication. These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools. ”

Is this part of a recurring concern?

Yes — Unreliable access to emergency communication.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to provide effective refresher training and information sharing for trained staff

Wider context from the report

“The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces. Is this a suggestion that could be given wider consideration? 1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious. However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving. 1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner. Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death. Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed? 2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration. I wonder whether there is a widespread lack of understanding of the best treatment in this situation? 3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records. 4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely? 1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy. 2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided. 3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER. 4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan. 5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan. 6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help? 7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay. 1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist. 2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting. 3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. 4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication. These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools. ”

Is this part of a recurring concern?

Yes — Inadequate staff training for emergency response.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of follow-up review tracking after replacement medication is requested

Wider context from the report

“The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces. Is this a suggestion that could be given wider consideration? 1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious. However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving. 1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner. Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death. Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed? 2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration. I wonder whether there is a widespread lack of understanding of the best treatment in this situation? 3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records. 4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely? 1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy. 2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided. 3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER. 4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan. 5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan. 6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help? 7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay. 1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist. 2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting. 3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. 4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication. These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools. ”

Is this part of a recurring concern?

Yes — Failure of case monitoring to identify cases requiring follow-up; Failure to reliably conduct clinically required medication reviews.

Open source report

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

Promote personalised written emergency plans for anaphylaxis and provide adaptable templates for healthcare professionals.

Verbatim wording from the response

“In addition, we have promoted the use of written personalised emergency management plans for anaphylactic reactions. We have developed templates which can be used by all healthcare professionals available on the BSACI website and these can be tailored to each individual’s personal circumstances and allergies.”

Source location

Response from British Society for Allergy and Clinical Immunology
Page 1 · response
Published 3 May 2023

Open published response

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

Produce national allergy-management guidelines through a NICE-accredited process.

Verbatim wording from the response

“We have produced a number of national guidelines using a process accredited by NICE (National Institute of Care Excellence) and these include the following:”

Source location

Response from British Society for Allergy and Clinical Immunology
Page 1 · response
Published 3 May 2023

Open published response

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

Support a campaign securing regulatory changes allowing schools to obtain spare adrenaline auto-injectors without prescription for emergencies.

Verbatim wording from the response

“BSACI have also been part of a campaign to ensure that schools can hold spare adrenaline auto-injectors without prescription for use in emergencies. This required an amendment to the Human Medicines Regulations Act 2012. We were informed last week that the amendment has been accepted (http://www.legislation.gov.uk/uksi/2017/715). The revised regulations will come into effect on 1 October 2017 and will allow schools to buy adrenaline auto-injectors without prescription for use in emergencies from a pharmaceutical supplier in small quantities provided it is done on an occasional basis and not for profit. Furthermore a working group has been set up to develop a website which will provide online resources to support school staff with this.”

Source location

Response from British Society for Allergy and Clinical Immunology
Page 1 · response
Published 3 May 2023

Open published response

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

Investigate whether secondary-care anaphylaxis care plans are already in place and used.

Verbatim wording from the response

“All our staff receives yearly BLS training and training around anaphylaxis. During this training the points above may or may not be emphasised by the trainer. We would share our learning around this at our bough with the safeguarding children team and discuss whether change can be implemented such that trainers organised to deliver this training emphasise the points highlighted if they also agree with these. By the end of September 2017, our nursing team will investigate whether there are anaphylaxis care plans that are already in place and being used by secondary care. We will then be incorporating these into care plans when seeing patients with asthma and allergies who have adrenaline prescriptions.”

Source location

Response from St Andrews Health Centre
Page 5 · response
Published 3 May 2023

Open published response

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 national and local guidance on appropriate inhaler-device prescribing and discuss the findings with clinical staff.

Verbatim wording from the response

“As a team, we have reviewed national and local guidance around appropriate prescriptions of inhaler devices. We have discussed this with nurses, specialist pharmacists and the rest of our clinical team. The guidance suggests, and widespread practice is, to prescribe the inhaler type that best suits the child. In Nasar's case this was an accuhaler. We could not find any guidance that those prescribed an accuhaler for preventer use should also be prescribed a metered dose inhaler with an aerochamber to be kept at home/school for emergencies. Furthermore, throughout all his specialist hospital reviews, this was not a suggestion made by our paediatric respiratory specialists.”

Source location

Response from St Andrews Health Centre
Page 3 · response
Published 3 May 2023

Open published response

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

Issue patients using accuhalers an MDI with spacer for emergencies and explain its purpose during asthma reviews.

Verbatim wording from the response

“On discussion we felt that it may be an expert opinion to additionally prescribe another inhaler with an aerochamber for emergency situations such as this but there isn't any broader local or national guidance that recommends this and if this is the most appropriate action, this needs to be highlighted at national level to feature in guidance so that systemic change can take place both within general practice but also at hospital level. We agree that an aerochamber is not suitable for an emergency situation where a patient may not have enough respiratory effort to take in the medication appropriately so as a practice we agreed that for patients using accuhalers, we would issue an MDI with spacer for use in emergencies and make it clear what this is for in the asthma review. This will be implemented from July 2017.”

Source location

Response from St Andrews Health Centre
Page 4 · response
Published 3 May 2023

Open published response

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 clinicians to document specified follow-up when an asthma test score is below 20/25.

Verbatim wording from the response

“On review of the literature, there is no specified guidance about what actions should be taken with different levels of asthma test scores- just that a score less than 20 may indicate poorly controlled asthma. Further national level guidance on this may be useful to avoid variations in action. At a clinical team meeting on 27th June 2017, we reflected on the point that at Nasar’s August 2016 asthma review, there was no follow up specified for the patient on finding that his asthma test score was 14/25. It was agreed that all clinicians must document specified follow up if the asthma test score is found to be suboptimal (i.e. <20/25). Who this review should be with and how soon it should take place would be agreed with the patient/parent on a case-by-case basis. This will be implemented immediately i.e. from June/July 2017. We hope this addresses all the queries raised in point 1.”

Source location

Response from St Andrews Health Centre
Page 3 · response
Published 3 May 2023

Open published response

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

Send children’s asthma action plans to school health teams or provide copies to parents for delivery to schools.

Verbatim wording from the response

“As a practice, we have agreed that our nursing team (who conduct the majority of our asthma reviews) will post/email a copy of the asthma action plan to the child’s school health team and/or a copy will be given to parents to hand into the school. This change will be implemented from July 2017.”

Source location

Response from St Andrews Health Centre
Page 4 · response
Published 3 May 2023

Open published response

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

Work with the borough safeguarding team to determine whether school nurses can access the community patient-record system for shared care-plan information.

Verbatim wording from the response

“We are currently in contact with our borough children’s safeguarding team to determine whether School nurses have access to the community version of our patient record system so that information about care plans can be input into this and this can be shared between us and the school nurses. Some hospital departments also have limited access to our patient record system- this may be a good way to share information. There needs to be borough wide (and national consideration around this). From a practice level, our clinical teams are checking for up to date and accurate care plans during asthma reviews- however, this case has further highlighted the importance of this.”

Source location

Response from St Andrews Health Centre
Page 4 · response
Published 3 May 2023

Open published response

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

Deliver tailored biannual school-nursing training covering record keeping, communication, action follow-up, electronic diaries and diary management.

Verbatim wording from the response

“In addition to the above training, the bi-annual training received by the school nursing service was delivered in June 2017. During bi-annual training, the service is suspended and training takes place across all staff groups. The training has been tailored to support the key learning points from the tragic death of Nasar Ahmed and the requirements and expectations of a school nurse. It covered a range of key areas including how to improve record keeping and the importance of this, the increased function of school nurse administrators in communication and following up of actions with key staff in school and the parents, the use of electronic diary systems and diary management. A copy of the training schedule undertaken in June 2017 is attached.”

Source location

Response from Compass Wellbeing
Page 4 · response
Published 3 May 2023

Open published response

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

Rewrite the IHCPs prepared by the involved nurse at Bow School to correct identified errors.

Verbatim wording from the response

“As part of CWB's investigation, each of the IHCPs prepared by this Nurse at Bow School were reviewed. CWB's investigation found that IHCPs prepared by the Nurse had errors in them and were required to be re-written. That process has now been completed.”

Source location

Response from Compass Wellbeing
Page 6 · response
Published 3 May 2023

Open published response

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

Roll out the electronic diarising system fully across the service in the new academic year.

Verbatim wording from the response

“All clinical staff have received guidance on how to manage an electronic diary in order to assist staff in diarising appointment, reminders and sharing calendar appointments. All clinical staff have access to mobile working devices, for example laptops, and the service is moving to a fully electronic diarising system in order to support sharing of appointment calendars and the effective use of an electronic diary and reminder system. Specific training on electronic diarising and the use of this took place on 21 June”

Source location

Response from Compass Wellbeing
Page 7 · response
Published 3 May 2023

Open published response

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

Prepare a Partnership Agreement defining school and School Health Service responsibilities, including school liaison arrangements for IHCPs and review meetings.

Verbatim wording from the response

“Following Nasar’s sad death CWB have prepared a Partnership Agreement between CWB and schools across the Borough of Tower Hamlets. This agreement sets out arrangements for support and training for education staff, as well as detailing the expectations across the organisational boundaries. Page 7 of the Agreement (copy enclosed) outlines the roles and responsibilities of the School Health Service and the school. It specifically requires that a member of staff will be identified who will liaise with the School Health Service. The identified school staff member is the person responsible for that child and who has”

Source location

Response from Compass Wellbeing
Page 4 · response
Published 3 May 2023

Open published response

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 school-nurse training requirements and deliver competency-framework retraining and IHCP training to staff.

Verbatim wording from the response

“CWB has also fully reviewed and identified the training received by school nurses and what they are required to receive in order to complete IHCPs in line with CWB's Competency Framework. The Competency Framework is a learning and development resource for nurses and this is completed upon their induction to the service. Re-training has been delivered in line with this Competency Framework. IHCP training has also been undertaken by all staff on 22 June 2017 in order to re-emphasise the role of a qualified nurse with reference to the guidance and the support of administering medication by non-”

Source location

Response from Compass Wellbeing
Page 3 · response
Published 3 May 2023

Open published response

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 a centralised IHCP database with renewal flags, notifications, data-team management and clinical oversight.

Verbatim wording from the response

“An IHCP improvement plan was subsequently implemented to identify, review and monitor all IHCPs across the service using a centralised database. This will support the identification of IHCPs requiring review which will be automatically flagged to the senior management team by an identified data manager. The database has been designed with a flagging system in it. The system counts down in days when an IHCP is due to be renewed and turns the date yellow 60 days prior to the expiry date and red once the date has arrived. The database will be managed by a data team on a daily basis and details of IHCP due (within 60 days) sent via email to the individual nurse responsible for the school and their line manager. This will be overseen by the clinical lead for the service and monitored as part of the performance data for the service.”

Source location

Response from Compass Wellbeing
Page 3 · response
Published 3 May 2023

Open published response

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 measures requiring school nurses to follow up and update IHCP meeting actions routinely.

Verbatim wording from the response

“CWB have implemented additional measures to ensure that the checking and updating of actions from IHCP meetings are routinely followed up by all school nurses and to prevent this event from happening again.”

Source location

Response from Compass Wellbeing
Page 7 · response
Published 3 May 2023

Open published response

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

Train clinical staff to use electronic diaries, reminders, shared calendars and mobile devices for appointment and action follow-up.

Verbatim wording from the response

“All clinical staff have received guidance on how to manage an electronic diary in order to assist staff in diarising appointment, reminders and sharing calendar appointments. All clinical staff have access to mobile working devices, for example laptops, and the service is moving to a fully electronic diarising system in order to support sharing of appointment calendars and the effective use of an electronic diary and reminder system. Specific training on electronic diarising and the use of this took place on 21 June”

Source location

Response from Compass Wellbeing
Page 7 · response
Published 3 May 2023

Open published response

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

Reinforce contemporaneous record keeping, action-point ownership and follow-up dates through medico-legal training and competency-framework training.

Verbatim wording from the response

“CWB have re-enforced to all staff the requirement and expectation across the service to ensure that accurate and contemporaneous records are kept, including recording and documenting action points and dates for follow up, as well as documenting who is responsible for each action point. This has been re-enforced through medico-legal training which was arranged for all staff in order to address the implications of poor documentation keeping and the effect this has on the delivery of healthcare. This training took place on 19 June 2017.”

Source location

Response from Compass Wellbeing
Page 8 · response
Published 3 May 2023

Open published response

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

Complete the whole-service IHCP Quality Standards Audit and extend the annual audit schedule to biannual IHCP audits.

Verbatim wording from the response

“A full Quality Standards Audit was commenced in June 2017 for IHCPs and is due to be completed in August 2017. This audit will review all IHCPs across the whole service. Once this audit has been completed, the annual audit schedule will be extended to include IHCP audits on a bi-annual basis. We will put in place a robust action plan to deal with any deficiencies identified.”

Source location

Response from Compass Wellbeing
Page 3 · response
Published 3 May 2023

Open published response

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

Continue delivering specific IHCP training on a biannual basis.

Verbatim wording from the response

“Specific IHCP training will continue to take place on a bi-annual basis. The next scheduled training is for September 2017.”

Source location

Response from Compass Wellbeing
Page 4 · response
Published 3 May 2023

Open published response

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

Support school nurses to encourage appropriate education staff to attend IHCP meetings.

Verbatim wording from the response

“In addition, school nurses are being supported to actively encourage appropriate members of education staff in the schools to be present during IHCP meetings. All school nurses are aware of the draft Partnership Agreement (see above) which states that there is a requirement for a school staff member to be present at these meetings. With the support of senior managers, school nurses will work to encourage the presence of school staff in IHCP meetings.”

Source location

Response from Compass Wellbeing
Page 5 · response
Published 3 May 2023

Open published response

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

Revise the asthma plan template and commence secure electronic sharing of individual asthma plans with schools and the School Health Service, supported by staff training.

Verbatim wording from the response

“Furthermore, as part of this partnership, CWB with the assistance of the respiratory clinical nurse specialist, has revised an asthma plan template for children and a process for sharing individual asthma plans with the school nursing service and schools has been commenced. A child’s individual asthma plan created by the GP/practice nurse or the specialist team will now be sent directly through to the School Health Service via secure generic email accounts. These email accounts are monitored on a daily basis. The plan will be attached to the child’s health record and an email sent to the relevant school nurse. Training has been given to our staff team.”

Source location

Response from Compass Wellbeing
Page 5 · response
Published 3 May 2023

Open published response

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

Introduce and scan a medication-review checklist into each child’s health record, with completion checked through biannual IHCP audits.

Verbatim wording from the response

“To assist with ensuring that medication is visually inspected by school nurses across the service at review meetings, a checklist has also been introduced for use during Individual Health Care Plan (“IHCP”) review meetings. This new measure is designed to ensure that all areas of the review process have been covered during the meeting. This new checklist will act as guidance and prompt to all school nurses and, once completed, will be scanned onto the Child’s Health Record. A copy of the ‘School annual review asthma/wheeze checklist’ is enclosed. The completion of this checklist will form part of the bi-annual IHCP audit, further details of which are provided later in this response.”

Source location

Response from Compass Wellbeing
Page 2 · response
Published 3 May 2023

Open published response

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

Remind staff that medication must be physically present for reviews and treat comparable breaches as gross misconduct with professional referral.

Verbatim wording from the response

“We have reminded all of our staff that there are no circumstances when a school nurse would not be expected to have the medication in front of them when conducting a review. Our staff have been reminded that we would consider a similar breach to be an act of gross misconduct and would also result in a professional conduct referral.”

Source location

Response from Compass Wellbeing
Page 2 · response
Published 3 May 2023

Open published response

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

Work with Tower Hamlets partners and head-teacher representatives to finalise and roll out the Partnership Agreement across schools.

Verbatim wording from the response

“the appropriate levels of authority to agree possible actions generated from an IHCP and who is able to disseminate information regarding the child’s care across the school, including what to do in an emergency. The staff member will work to ensure support and consistency is provided by the school and School Health Service, particularly in relation to the creation of IHCPs and attendance at review meetings. CWB is currently working with the London Borough of Tower Hamlets Public Health and Education departments, as well as Tower Hamlets head teachers representatives, to finalise and roll out the agreements across all schools.”

Source location

Response from Compass Wellbeing
Page 5 · response
Published 3 May 2023

Open published response

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

Develop guidance for school staff on obtaining and appropriately using spare adrenaline auto-injectors, including general advice on adrenaline use.

Verbatim wording from the response

“Our amendments to the Human Medicines Regulations 2012, Parliament permitting, will come into effect on 1 October 2017. Officials are currently working on guidance for school staff on how to obtain and use these auto-injectors appropriately, and the guidance will also provide advice on use of adrenaline more generally. Clinicians from the Anaphylaxis Campaign, as well as lay people, are advising on the content of this guidance, and we are hoping to also bring together training videos on different auto-injectors in a single website.”

Source location

Response from Department of Health and Social Care
Page 4 · response
Published 3 May 2023

Open published response

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

Bring amendments to the Human Medicines Regulations 2012 into effect to allow schools to hold spare adrenaline auto-injectors for eligible children.

Verbatim wording from the response

“However, I am hopeful that work underway to change the law to allow schools to hold spare auto-injectors without a named individual prescription, for use as emergency back-up to treat anaphylaxis in children registered at the school as being in receipt of a medical prescription for an auto-injector, will tackle some of the challenges which staff faced in this sad case, and which were set out in your determination.”

Source location

Response from Department of Health and Social Care
Page 4 · response
Published 3 May 2023

Open published response

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

Bring the completed guidance to the attention of schools.

Verbatim wording from the response

“I hope that this guidance, which we will bring to the attention of schools, will greatly reduce the likelihood of a repetition of the tragic events which led to the death of Nasar Ahmed, and so save other lives.”

Source location

Response from Department of Health and Social Care
Page 4 · response
Published 3 May 2023

Open published response

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 pastoral staff to attend initial and review meetings for Individual Health Care Plans.

Verbatim wording from the response

“Notwithstanding this the school has revised the relevant policy to require that a member of pastoral team responsible for the child, (usually the Year Learning Manager [YLM] or the Year Learning Assistant [YLA]) attends the initial meeting and all reviews. It has also been amended so it no longer requires a first aider to contact the headteacher’s personal assistant to call emergency services, but rather requires staff do this immediately and then”

Source location

Response from Bow School
Page 1 · response
Published 3 May 2023

Open published response

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 all pupil Individual Health Care Plans and verify that emergency-box medicines are prescribed and in date.

Verbatim wording from the response

“The Coroner also raised concerns that the system in place for ensuring that actions arising from individual health plans (‘IHP’) and medication reviews were undertaken was not sufficiently robust. Since Nasar’s death, the school’s Safeguarding Committee has undertaken a thorough review of all IHPs for pupils in the school. This included ensuring that all medicines kept within emergency boxes at the school are as prescribed and in date.”

Source location

Response from Bow School
Page 2 · response
Published 3 May 2023

Open published response

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

Use Safeguarding Committee governance, scheduling, spot checks and compliance reporting to monitor Individual Health Care Plans and medicines.

Verbatim wording from the response

“The Safeguarding Committee⁵ has developed a flowchart to outline the responsibilities under the ‘Support students with medical needs’ policy. The committee has an agenda item ‘IHP and medication reviews’ so that effectiveness of managing medical needs is considered at each meeting. It is responsible for setting the schedule of meetings for all IHP or medication reviews on a half termly basis. The school administrator is required to liaise with Compass Wellbeing and the YLM to ensure all parties are present at meetings. The Designated Safeguarding Lead (‘DSL’) also receives details of IHP meetings and the decisions made and conducts spot checks on the IHPs and medicines so that compliance with expectations can be maintained. The DSL provides a compliance report each half term to the safeguarding committee.”

Source location

Response from Bow School
Page 2 · response
Published 3 May 2023

Open published response

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

Provide all staff access to pupils’ medical-needs information through electronic registers and require confirmation that key medical-needs and safeguarding policies are understood.

Verbatim wording from the response

“The Coroner commented that school staff were encouraged to familiarise themselves with pupil’s care plans and required to do so for school excursions, but in other circumstances staff may not have been familiar with health needs of all pupils. In response to this the school now have a clear understanding between Compass Wellbeing, parents and pupils that information regarding a child’s medical needs will be shared with all staff on the basis that all staff need to have access to, and understanding of, this information. This information has been made more visible for staff as detailed below and policies and processes have been revised to reflect this common understanding, for example, all staff have access to the school’s electronic medical needs registers. The amended policies are due to be ratified by the Governing Body on the 12.07.17.”

Source location

Response from Bow School
Page 3 · response
Published 3 May 2023

Open published response

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

Hold monthly school-nurse meetings for trained first aiders to share current advice, guidance and practice.

Verbatim wording from the response

“Those members of staff who have already completed a HSE approved first aid training course will, from September 2017, meet monthly with the school nurse to share information and review latest advice, guidance and practice. The school’s half-termly safeguarding bulletins contain an updated list of all first aiders in the school and they have agreed to run regular briefings for staff at the start of each half-term. They will also run briefings for pupils on a rolling programme so that there is increased awareness of who on the staff team have first aid training.”

Source location

Response from Bow School
Page 5 · response
Published 3 May 2023

Open published response

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

Deliver additional HSE-approved first-aid training, prioritising staff supervising higher-risk or small-group settings.

Verbatim wording from the response

“The school is also grateful for the opportunity this report affords them to provide assurance that staff and pupils have been offered additional first aid training and to report that the whole school community have embraced those opportunities. A further 25 members of staff have volunteered to complete a first aid course approved by the HSE over the next academic year, many have already completed their training including all staff responsible for supervising internal exclusion room. The safeguarding committee have devised a first aid training plan, which was presented to and approved by the Governing Body’s standards committee on the 14.06.17. This ensures that staff supervising areas of small group work, learning assistants and those who lead in higher risk subjects (e.g. PE, technology and science) are prioritised for HSE first aid training.”

Source location

Response from Bow School
Page 5 · response
Published 3 May 2023

Open published response

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

Brief staff on recognising and responding to escalating asthma and anaphylaxis symptoms, and repeat the briefing.

Verbatim wording from the response

“On the 05.06.17 a member of the Governing Body who is also a GP provided a briefing to all staff on the policy and procedures for supporting students with medical needs. . He explained how to identify Asthma and Anaphylaxis symptoms which indicate medical needs were escalating or becoming critical and how to respond. This briefing is due to be repeated in September 2017.”

Source location

Response from Bow School
Page 5 · response
Published 3 May 2023

Open published response

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

Provide asthma, allergy and EpiPen training to staff who have completed HSE first-aid training, alongside refresher training.

Verbatim wording from the response

“First aid training programmes are added to the calendar at the start of each academic year, with staff identified for each course. This can only be amended on the authority of the Headteacher. In addition, those who have already completed their HSE first aid programme will receive an additional one-day training on asthma, allergies and Epi-Pen. This is in addition to the first aid training at work refresher courses.”

Source location

Response from Bow School
Page 5 · response
Published 3 May 2023

Open published response

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

Brief staff on pupils’ medical needs, provide recurring reminders and conduct Safeguarding Committee compliance spot checks.

Verbatim wording from the response

“The school’s SENDCo will provide briefings to all staff for children with medical needs each September. Further briefings will be provided to all staff if a child with medical needs starts in year and all new staff receive the briefing as part of their induction if they do not start in September or if a child’s needs change following a review. All staff received a briefing on the pupils with medical needs on the 05.06.17 and will receive half-termly reminders. Those reminders will also require they review their ‘class context sheets’ to ensure medical information for students is up to date. The Safeguarding Committee will undertake spot checks to ensure compliance, the first of which will be completed by the 04.07.17.”

Source location

Response from Bow School
Page 3 · response
Published 3 May 2023

Open published response

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

Display asthma and allergic-reaction response posters throughout the school.

Verbatim wording from the response

“To raise awareness more widely across the school posters have been placed in all classrooms and throughout the school, including in the dining pavilion. These detail the steps to take where someone is having an asthma attack or allergic reaction. Allergens posters continue to be placed at key sites within the dining pavilion and menus will be annotated with all allergens, not just at Bow School but in all schools supplied by the catering provider. The Executive Headteacher is working closely with the catering provider to ensure that catering staff are trained and aware of their responsibilities within the school’s policies and has been assured that the annotated menus will be in place by the beginning of September 2017.”

Source location

Response from Bow School
Page 5 · response
Published 3 May 2023

Open published response

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

Maintain and half-termly update prominently displayed registers of pupils with medical needs, including symptoms and key actions.

Verbatim wording from the response

“Since the Inquest the Deputy Head teacher responsible for safeguarding has reviewed all information held in respect of children with medical needs to ensure that the IHP register, Asthma Register, Allergies Register and Other conditions register is accurate. The registers are now discreetly displayed by type of need, the pupil’s name and photograph, symptoms and key actions in each of the staff common areas, the kitchen, learning support areas and internal exclusion room. These are reviewed and updated on a half-termly basis.”

Source location

Response from Bow School
Page 4 · response
Published 3 May 2023

Open published response

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

Attach Individual Health Care Plans and medical alerts to electronic pupil records and add allergy alerts to the cashless catering system.

Verbatim wording from the response

“In addition, all IHPs are being scanned and attached to the relevant child’s electronic record (the SIMS profile) so that it can be viewed quickly by staff. An alert symbol has also been added to relevant pupils’ SIMS profiles so that it is immediately visible if a child has an IHP. Alerts have also been added to the school’s Cashless Catering System to flag students with allergies so that staff are aware of those children. Catering staff are encouraged to liaise with the relevant pastoral team or Compass Wellbeing to check if unsure and continue to challenge if they feel a pupil’s choice may place them at risk. There is also a procedure for catering staff to report concerns where children with allergies regularly seek to purchase food containing allergens.”

Source location

Response from Bow School
Page 3 · response
Published 3 May 2023

Open published response

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 monitored procedures for arranging and following up Individual Health Care Plan and medication reviews, including senior oversight and deadline reminders.

Verbatim wording from the response

“The Executive Headteacher, along with Headteacher representatives from across the area, has been invited by the Local authority to meet to discuss the school nursing service as part of a scheduled contract renewal process. This meeting is due to take place later this year, but it is understood that the concerns identified during the Inquest will inform that process. In the interim the school has been working with Compass Wellbeing to clarify the procedure for setting up IHP meetings and medication reviews. The school has had additional processes to ensure this procedure is robustly monitored at senior level. The procedure requires that, in all cases an update of the pupil’s medical need is required at each review.”

Source location

Response from Bow School
Page 2 · response
Published 3 May 2023

Open published response

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

Standardise acute and chronic asthma management across Tower Hamlets in line with London paediatric asthma standards and relevant quality standards.

Verbatim wording from the response

“We have considered the circumstances around Nasar Ahmed’s death and each of the concerns you raise. We have addressed these concerns in the form of an action plan attached. In addition to actions addressing the concerns specified in your report we will work with partners to fulfil the following system wide actions:”

Source location

Response from Barts Health NHS Trust
Page 1 · response
Published 3 May 2023

Open published response

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

An accuhaler was considered appropriate for the child's preventer treatment; guidance did not require an additional emergency metered-dose inhaler with spacer.

Verbatim wording from the response

“Point 2 states that the asthma pump in Nasar's medication box was an accuhaler which is inappropriate for an emergency situation and that the appropriate inhaler should have been prescribed with a spacer. You wonder whether there is a wide spread lack of understanding about this.”

Source location

Response from St Andrews Health Centre
Page 3 · response
Published 3 May 2023

Open published response

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

Existing records-system alerts and enhanced asthma-review recalls already identify patients receiving excessive short-acting beta agonist inhalers.

Verbatim wording from the response

“Point 1 states that Nasar's report of symptoms to his consultant didn't correlate with the GPs findings, that his lung function tests were good, that GP prescribed 30 inhalers which is a recognised risk factor for death and that he should have been seen by the consultant again. The point queries whether an automatic flag could be raised if excess medication is prescribed.”

Source location

Response from St Andrews Health Centre
Page 2 · response
Published 3 May 2023

Open published response

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

Checking that in-date medication is provided is a shared responsibility between the school and school nurse.

Verbatim wording from the response

“The Supporting Medical Needs Policy indicates that the responsibility of checking that in-date medication is provided is a shared one between the school itself and the school nurse. It is fully expected that the school nurse and the school would have a conversation to discuss follow-up actions arising from a meeting and appropriately diarise to check that the correct medication has been received and, if not received, to chase this up in a timely manner. As a qualified health professional, the school nurse is able and expected to understand whether a prescription is appropriate and whether the correct medication has been received. Any outstanding actions must be followed up and completed as a matter of course and in accordance with their professional duties.”

Source location

Response from Compass Wellbeing
Page 7 · response
Published 3 May 2023

Open published response

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

Schools share responsibility for preparing and updating IHCPs and ensuring an appropriate school representative attends review meetings.

Verbatim wording from the response

“CWB recognises and understands the importance of the collaborative working arrangements involved in preparing IHCPs and the ongoing support, communication and processes for children in schools with medical conditions. The Supporting Medical Needs Policy clearly sets out that a number of organisations have roles and responsibilities and that school staff, school nurses and parents must work in partnership to ensure that the needs of pupils with medical conditions are met effectively.”

Source location

Response from Compass Wellbeing
Page 4 · response
Published 3 May 2023

Open published response

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

Parents or the school nurse are principally responsible for contacting the pupil’s GP or other treating medical professionals before reviews.

Verbatim wording from the response

“Principally it remains the responsibility of the child’s parents or school nurse to make contact with the child’s GP or other medical professionals involved in their care prior to the meeting. Where, at the review meeting, this hasn’t been done or there is any uncertainty regarding the pupil’s current need the school nurse is required to follow up with direct contact to the pupil’s GP and confirm the position to the school administrator by email. The deputy head responsible for safeguarding is also copied into those emails. The procedure also differentiates between medication reviews and IHP meetings/reviews to ensure that necessary follow up can be scheduled separately. For example, where actions are required as a result of the medication review, a follow up review is scheduled for the following week.”

Source location

Response from Bow School
Page 2 · response
Published 3 May 2023

Open published response

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

School staff are not expected to perform first aid to the standard of clinicians; guidance requires only their best endeavours to secure pupil welfare.

Verbatim wording from the response

“The Coroner rightly recognised within the narrative determination this was ‘a very pressured situation’. She queried whether staff may have responded differently if they had received training or, for those who had, whether they may benefit from additional first aid training. It is important to highlight that staff administering first aid are not expected to perform those responsibilities to the standard of clinicians trained to perform emergency medical interventions where they are held. The guidance simply requires that staff use their ‘best endeavours’ to secure the welfare of the pupil. It is understood that the Coroner did not intend her comments to be taken as a criticism of the actions of staff on that day. To do so may well have an unintended consequence of deterring otherwise willing volunteers from taking on these vital responsibilities.”

Source location

Response from Bow School
Page 4 · response
Published 3 May 2023

Open published response

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

There is no requirement for all school staff to be first aiders, and teachers are not contractually required to provide first aid.

Verbatim wording from the response

“A fourth issue identified by the Coroner was that not everyone involved in trying to help Nasar was first aid trained. This is correct, however, there is no requirement that all school staff are first aiders. The ‘First aid in schools’ guidance⁶ is explicit that it is not a condition of a teacher’s employment contract that they provide first aid. It is a matter for individuals whether they wish to volunteer for those responsibilities, though as an employer a school’s Governing Body must ensure that they have sufficient first aiders to provide first aid for school staff. The Health and Safety Executive (‘HSE’) advises that organisations such as schools consider possible risks to pupils and visitors within their risk assessments and allow for this when determining the number of first aiders personnel they may require.”

Source location

Response from Bow School
Page 4 · response
Published 3 May 2023

Open published response

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 had an appropriate number of first aiders on site at all times, including when the death occurred.

Verbatim wording from the response

“It is important to clarify that the school does have an appropriate number of first aiders on site at all times including, on the 10.11.16. Furthermore, whilst it wasn’t referenced within the narrative determination, the school’s arrangements to safeguard students was subject to review by OFSTED on the 17.11.16 and found to be effective, in particular OFSTED commended the rigour of risk assessments for school trips.”

Source location

Response from Bow School
Page 4 · response
Published 3 May 2023

Open published response

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’s policy did not require staff attendance at annual Individual Health Care Plan reviews and complied with relevant national guidance.

Verbatim wording from the response

“The Coroner commented within the report that Nasar’s mother was present for the medication review conducted by the school nurse on the 03.05.16, but that a member of staff wasn’t present. She commented that this was contrary to the school policy. It should be noted that, at time of Nasar’s death, the ‘Supporting Student with medical needs’ policy did not require a member of staff to attend the annual review of an Individual Health Care Plan; rather the requirement was that staff were involved in the original decision to have a plan.¹ It should also be noted that this policy complied with the standards expected by national guidance for schools including ‘Supporting pupils at school with medical conditions statutory guidance for governing bodies’,² the ‘Special Educational Needs and Disability Code of Practice’³ and ‘Keeping children safe in Education’.⁴”

Source location

Response from Bow School
Page 1 · response
Published 3 May 2023

Open published response

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 paramedic did not advise against using the EpiPen; the call was appropriately managed while necessary information was sought.

Verbatim wording from the response

“At no point does the paramedic advise the caller not to use an EpiPen.”

Source location

Response from London Ambulance Service NHS Trust
Page 2 · response
Published 3 May 2023

Open published response

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

No action will be taken because the call was appropriately managed and the reported advice was not given.

Verbatim wording from the response

“It is our conclusion that the call was appropriately managed by the call handler in trying to elicit the necessary information and it is clear from the transcript provided to you that the Clinical Hub paramedic did not advise Bow School not to use the EpiPen.”

Source location

Response from London Ambulance Service NHS Trust
Page 2 · response
Published 3 May 2023

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.17

  1. 1

    Implement the Radar Incident Reporting System to record, investigate, prioritise and track incidents, risks, actions, alerts and reviews.

    Stated by Compass Wellbeing CICStated in progressThe respondent said that this action was in progress when they made their response on 3 May 2023.
  2. 2

    Send joint letters to Tower Hamlets head teachers explaining asthma-friendly schools and school and School Health Service expectations.

    Stated by Compass Wellbeing CICStated completedThe respondent said that this action was complete when they made their response on 3 May 2023.
  3. 3

    Meet termly with Compass Wellbeing managers to review policy implementation, communications, compliance and staff training needs.

    Stated by Bow SchoolStated in progressThe respondent said that this action was in progress when they made their response on 3 May 2023.
  4. 4

    Meet Anaphylaxis Campaign representatives to discuss supporting its campaign and broader awareness-raising.

    Stated by Bow SchoolStated plannedThe respondent said that this action was planned when they made their response on 3 May 2023.
  5. 5

    Include medical-needs awareness lessons in the PSHE curriculum.

    Stated by Bow SchoolStated plannedThe respondent said that this action was planned when they made their response on 3 May 2023.
  6. 6

    Deliver a themed healthy-living day addressing how pupils can support students with medical needs.

    Stated by Bow SchoolStated plannedThe respondent said that this action was planned when they made their response on 3 May 2023.
  7. 7

    Amend staff induction to include medical-needs information, access training, first-aid opportunities and policy responsibility charts.

    Stated by Bow SchoolStated in progressThe respondent said that this action was in progress when they made their response on 3 May 2023.
  8. 8

    Issue regular staff and pupil briefings identifying trained first aiders and promoting awareness of medical-emergency support.

    Stated by Bow SchoolStated plannedThe respondent said that this action was planned when they made their response on 3 May 2023.
  9. 9

    Annotate catering menus with all allergens and train catering staff on their medical-needs responsibilities.

    Stated by Bow SchoolStated in progressThe respondent said that this action was in progress when they made their response on 3 May 2023.
  10. 10

    Ratify the revised medical-needs policies at the Governing Body meeting.

    Stated by Bow SchoolStated plannedThe respondent said that this action was planned when they made their response on 3 May 2023.
  11. 11

    Require staff to call emergency services immediately and notify the office so parents can be informed promptly.

    Stated by Bow SchoolStated completedThe respondent said that this action was complete when they made their response on 3 May 2023.
  12. 12

    Collect and share medical information for transferring and newly admitted pupils so Individual Health Care Plans and medication requirements are ready at the school-year start.

    Stated by Bow SchoolStated completedThe respondent said that this action was complete when they made their response on 3 May 2023.
  13. 13

    Offer first-aid training to Year 9 pupils and extend it to all pupils in the following academic year.

    Stated by Bow SchoolStated plannedThe respondent said that this action was planned when they made their response on 3 May 2023.
  14. 14

    Implement the Asthma Friendly Schools Project with partner organisations.

    Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 3 May 2023.
  15. 15

    Enhance knowledge of childhood long-term conditions to improve self-management across health, education and individuals.

    Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 3 May 2023.
  16. 16

    Require universal use of the Healthy London Partnership paediatric asthma toolkit to train health and education staff.

    Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 3 May 2023.
  17. 17

    Share the Regulation 28 response with the Association of Ambulance Chief Executives and National Ambulance Service Medical Directors.

    Stated by London Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 3 May 2023.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Generic adrenaline auto-injectors will not be pursued for public storage because their risks and practical complexities outweigh potential benefits.

    Stated by Department of Health and Social CareNo action considered necessaryThe respondent said that no further action was needed.

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 the Radar Incident Reporting System to record, investigate, prioritise and track incidents, risks, actions, alerts and reviews.

Verbatim wording from the response

“CWB has also initiated a Project Plan for an incident reporting system called the ‘Radar Incident Reporting System’. This system is used to record incidents and risks within the organisation and also highlights where communication difficulties occur, including where IHCP meetings need to be postponed due to non-attendance of education staff. The Radar Healthcare risk register will enable CWB to fully record and manage the major risks to the organisation and the objectives that they compromise. Risks are prioritised and can be linked to existing incidents and complaints that have been recorded. The system allows regional and corporate risk registers to be managed, with actions, alerts and reviews being tracked to ensure effective risk management.”

Source location

Response from Compass Wellbeing
Page 5 · response
Published 3 May 2023

Open published response

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

Send joint letters to Tower Hamlets head teachers explaining asthma-friendly schools and school and School Health Service expectations.

Verbatim wording from the response

“Alongside this, joint letters have been sent to all school head teachers within the Borough of Tower Hamlets detailing how schools can become “asthma friendly”. This also outlines the expectations and requirements of the school and the School Health Service. This has been prepared and sent in partnership with the specialist teams led by ████████ (from whom you heard evidence at the inquest).”

Source location

Response from Compass Wellbeing
Page 5 · response
Published 3 May 2023

Open published response

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

Meet termly with Compass Wellbeing managers to review policy implementation, communications, compliance and staff training needs.

Verbatim wording from the response

“In addition, senior leaders at the school meet with Compass Wellbeing managers on a termly basis to review practice, the implementation of the policy and procedures and to assess the quality of communications between the school nursing service and pastoral teams within the school. Any concerns regarding compliance with those expectations or training needs of staff are also addressed at that meeting.”

Source location

Response from Bow School
Page 2 · response
Published 3 May 2023

Open published response

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

Meet Anaphylaxis Campaign representatives to discuss supporting its campaign and broader awareness-raising.

Verbatim wording from the response

“On the 11.07.17 the Deputy Head will meet with ████████ of Anaphylaxis Campaign, an awareness raising charity, to discuss how the school could support the work of their campaign and raise awareness more generally. Thereafter, on the 13.07.17 pupils will not be required to follow their usual timetable, instead there will be a themed day of activities and learning opportunities on healthy living. As part of this staff will be raising awareness of what pupils can do to support students with medical needs. The PSHE curriculum will include medical needs awareness lessons. Year 9 pupils will be offered first aid training in July 2017, this will be extended to all pupils in the next academic year.”

Source location

Response from Bow School
Page 5 · response
Published 3 May 2023

Open published response

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

Include medical-needs awareness lessons in the PSHE curriculum.

Verbatim wording from the response

“On the 11.07.17 the Deputy Head will meet with ████████ of Anaphylaxis Campaign, an awareness raising charity, to discuss how the school could support the work of their campaign and raise awareness more generally. Thereafter, on the 13.07.17 pupils will not be required to follow their usual timetable, instead there will be a themed day of activities and learning opportunities on healthy living. As part of this staff will be raising awareness of what pupils can do to support students with medical needs. The PSHE curriculum will include medical needs awareness lessons. Year 9 pupils will be offered first aid training in July 2017, this will be extended to all pupils in the next academic year.”

Source location

Response from Bow School
Page 5 · response
Published 3 May 2023

Open published response

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

Deliver a themed healthy-living day addressing how pupils can support students with medical needs.

Verbatim wording from the response

“On the 11.07.17 the Deputy Head will meet with ████████ of Anaphylaxis Campaign, an awareness raising charity, to discuss how the school could support the work of their campaign and raise awareness more generally. Thereafter, on the 13.07.17 pupils will not be required to follow their usual timetable, instead there will be a themed day of activities and learning opportunities on healthy living. As part of this staff will be raising awareness of what pupils can do to support students with medical needs. The PSHE curriculum will include medical needs awareness lessons. Year 9 pupils will be offered first aid training in July 2017, this will be extended to all pupils in the next academic year.”

Source location

Response from Bow School
Page 5 · response
Published 3 May 2023

Open published response

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

Amend staff induction to include medical-needs information, access training, first-aid opportunities and policy responsibility charts.

Verbatim wording from the response

“In addition, the induction programme for new staff has been amended to include medical needs information in induction packs and training is provided to all new staff on how to access medical needs information on the pupil’s SIMS record. All staff are also offered training with Compass Wellbeing on basic first aid. All staff are required to sign to confirm they have read and understood key policies in relation to medical needs and safeguarding. The school has also devised roles and responsibilities charts for key policies, such as:”

Source location

Response from Bow School
Page 3 · response
Published 3 May 2023

Open published response

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

Issue regular staff and pupil briefings identifying trained first aiders and promoting awareness of medical-emergency support.

Verbatim wording from the response

“Those members of staff who have already completed a HSE approved first aid training course will, from September 2017, meet monthly with the school nurse to share information and review latest advice, guidance and practice. The school’s half-termly safeguarding bulletins contain an updated list of all first aiders in the school and they have agreed to run regular briefings for staff at the start of each half-term. They will also run briefings for pupils on a rolling programme so that there is increased awareness of who on the staff team have first aid training.”

Source location

Response from Bow School
Page 5 · response
Published 3 May 2023

Open published response

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

Annotate catering menus with all allergens and train catering staff on their medical-needs responsibilities.

Verbatim wording from the response

“To raise awareness more widely across the school posters have been placed in all classrooms and throughout the school, including in the dining pavilion. These detail the steps to take where someone is having an asthma attack or allergic reaction. Allergens posters continue to be placed at key sites within the dining pavilion and menus will be annotated with all allergens, not just at Bow School but in all schools supplied by the catering provider. The Executive Headteacher is working closely with the catering provider to ensure that catering staff are trained and aware of their responsibilities within the school’s policies and has been assured that the annotated menus will be in place by the beginning of September 2017.”

Source location

Response from Bow School
Page 5 · response
Published 3 May 2023

Open published response

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

Ratify the revised medical-needs policies at the Governing Body meeting.

Verbatim wording from the response

“notify the office so that parents can be informed at the earliest opportunity. The revised policies are due to be ratified at the next Governing Body meeting on the 12.07.17, but staff have already implemented these changes into their practice.”

Source location

Response from Bow School
Page 2 · response
Published 3 May 2023

Open published response

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 staff to call emergency services immediately and notify the office so parents can be informed promptly.

Verbatim wording from the response

“Notwithstanding this the school has revised the relevant policy to require that a member of pastoral team responsible for the child, (usually the Year Learning Manager [YLM] or the Year Learning Assistant [YLA]) attends the initial meeting and all reviews. It has also been amended so it no longer requires a first aider to contact the headteacher’s personal assistant to call emergency services, but rather requires staff do this immediately and then”

Source location

Response from Bow School
Page 1 · response
Published 3 May 2023

Open published response

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

Collect and share medical information for transferring and newly admitted pupils so Individual Health Care Plans and medication requirements are ready at the school-year start.

Verbatim wording from the response

“The school extended this support to children in transition, i.e. those moving into the school from Year 6 and in year admissions from other schools. Staff use opportunities such as school visits and induction days to request medical information from parents and the child’s current school records. This information is shared with Compass Wellbeing so IHP and medication requirements can be reviewed over the summer holidays and are in place at the start of each school year. This also protects against any gap in IHP or medication reviews.”

Source location

Response from Bow School
Page 3 · response
Published 3 May 2023

Open published response

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

Offer first-aid training to Year 9 pupils and extend it to all pupils in the following academic year.

Verbatim wording from the response

“On the 11.07.17 the Deputy Head will meet with ████████ of Anaphylaxis Campaign, an awareness raising charity, to discuss how the school could support the work of their campaign and raise awareness more generally. Thereafter, on the 13.07.17 pupils will not be required to follow their usual timetable, instead there will be a themed day of activities and learning opportunities on healthy living. As part of this staff will be raising awareness of what pupils can do to support students with medical needs. The PSHE curriculum will include medical needs awareness lessons. Year 9 pupils will be offered first aid training in July 2017, this will be extended to all pupils in the next academic year.”

Source location

Response from Bow School
Page 5 · response
Published 3 May 2023

Open published response

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 the Asthma Friendly Schools Project with partner organisations.

Verbatim wording from the response

“We have considered the circumstances around Nasar Ahmed’s death and each of the concerns you raise. We have addressed these concerns in the form of an action plan attached. In addition to actions addressing the concerns specified in your report we will work with partners to fulfil the following system wide actions:”

Source location

Response from Barts Health NHS Trust
Page 1 · response
Published 3 May 2023

Open published response

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

Enhance knowledge of childhood long-term conditions to improve self-management across health, education and individuals.

Verbatim wording from the response

“We have considered the circumstances around Nasar Ahmed’s death and each of the concerns you raise. We have addressed these concerns in the form of an action plan attached. In addition to actions addressing the concerns specified in your report we will work with partners to fulfil the following system wide actions:”

Source location

Response from Barts Health NHS Trust
Page 1 · response
Published 3 May 2023

Open published response

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 universal use of the Healthy London Partnership paediatric asthma toolkit to train health and education staff.

Verbatim wording from the response

“We have considered the circumstances around Nasar Ahmed’s death and each of the concerns you raise. We have addressed these concerns in the form of an action plan attached. In addition to actions addressing the concerns specified in your report we will work with partners to fulfil the following system wide actions:”

Source location

Response from Barts Health NHS Trust
Page 1 · response
Published 3 May 2023

Open published response

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

Share the Regulation 28 response with the Association of Ambulance Chief Executives and National Ambulance Service Medical Directors.

Verbatim wording from the response

“This Regulation 28 response will be shared with the Association of Ambulance Chief Executives and the National Ambulance Service Medical Directors.”

Source location

Response from London Ambulance Service NHS Trust
Page 2 · response
Published 3 May 2023

Open published response

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

Generic adrenaline auto-injectors will not be pursued for public storage because their risks and practical complexities outweigh potential benefits.

Verbatim wording from the response

“In giving this consideration, I have taken advice from the Medicines and Healthcare Products Regulatory Agency (MHRA). The MHRA, having deliberated on this, considers such an action could pose substantial risks that outweigh potential for benefit and would need careful evaluation. The MHRA has both clinical and technical concerns.”

Source location

Response from Department of Health and Social Care
Page 1 · response
Published 3 May 2023

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026