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Investigation and inquest
On 12 July 2017 I commenced an investigation into the death of Karanbir Cheema, aged 13 years. The investigation concluded at the end of the inquest today. I made a narrative determination at inquest, which I attach to this letter.
Circumstances of the death
Karanbir was attended William Perkin High School. On Wednesday, 28 June 2017, another pupil threw a small piece of cheese at him. He was known to be allergic to cheese and he went into anaphylactic shock.
His medical cause of death was:
1a post cardiac arrest syndrome
1b anaphylactic shock
1c multiple food allergies
2 bronchial asthma
Coroner’s concerns
I am aware that some changes have been made since Karanbir’s death and therefore do not need to be re-iterated now, but others remain outstanding. Some issues I raised before Karanbir’s death, in PFD reports I made in May 2017 following the death of Nasar Ahmed on 14 November 2016.
1. The pupils at Karanbir’s school had a patchy understanding of his allergies, what they were and the consequences of exposure to allergens. Targeted education about this would improve safety.
2. Karanbir’s school care plan and medical box were not checked or audited to ensure, for example, that his care plan stipulated two EpiPens® (adrenaline auto-injectors), the box contained two EpiPens.
3. Karanbir’s EpiPen was out of date. There must be systems in place to ensure that medication in schools is in date.
4. Allergy action plans are not standardised across hospitals and schools, so messages are not as clearly delivered as they could be. This is vital particularly when they may be read for the first time in a desperate situation where panic has set in.
5. The allergy action plan drafted by Karanbir’s doctors at Ealing Hospital did not find its way to his school. There is no standardised approach to this, for example always sending a copy to the school designated safeguarding lead, as well as giving parents/carers a copy for themselves and a copy for the school in case the posted version does not arrive.
6. Karanbir’s treating doctors wanted him to re-attend for asthma and allergy review four months after his last consultation. An appointment was made but cancelled by the hospital. By the time of his death four months later he had still not been seen again. There needed to be recognition of the time critical nature of this appointment. It needed to be re-booked without delay.
7. Karanbir had one EpiPen at home, one at school and one at his father’s home. There is clearly a need for medical teams to emphasise that two EpiPens must be available at all times.
8. There appears to be a lack of awareness nationally of the simple but vital messages that:
- if a person with an allergy has been exposed to an allergen and develops any respiratory compromise, so any breathing difficulty at all, then adrenaline (via EpiPen or other) should be administered immediately, before any asthma pump and even before calling for help;
- if there is a deterioration after giving one EpiPen, then another should be administered immediately, or in any event after five minutes if there is no improvement.
9. The EpiPen box does not contain these instructions on the outside.
10. These instructions were not communicated effectively as part of the school staff’s first aid and EpiPen training.
11. The London Ambulance Service 999 operator did not at any time suggest that a second EpiPen be given, because this is not contained within the algorithm. That could be remedied internationally.
12. The allergy specialist who gave evidence was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
This was the view of the respiratory physician who gave evidence in May 2017 and about which I wrote then to the Chief Medical Officer for England. Is this worthy of reconsideration?
Information checked against the published report and official responses