Tiya Chetan Chauhan · Prevention of Future Deaths report

On 31st August 2012 I commenced an investigation into the death Miss Tiya Chetan Chauhan aged 22 months. The investigation concluded at the end of the inquest on the 4th September 2014. The conclusion of the inquest found by the jury was:

Medical Cause of Death

1 (a) Cerebral hypoxia

(b) Asphyxia

(c) Inhalation of foreign body

How, when and where the deceased came by her death:

Tiya died on 24/08/2012 at St George’s Hospital Tooting as a result of cerebral hypoxia caused by an obstruction in her airway. The obstruction was a cube of raw jelly. The cube of raw jelly was left in the sensory tray activity at Dicky Birds Nursery, Dundonald Road on 23/08/12 during nursery set up.

Tiya was able to access the sensory tray during “free flow” time.

The jelly cube was taken form the tray unseen by the nursery staff.

The jelly was inhaled into Tiya’s airway unseen by the nursery staff.

Tiya’s airway became obstructed and she collapsed unseen by the nursery staff.

Found unconscious on the floor, CPR was administered but she did not regain consciousness and died on 24/08/2012 at St Georges Hospital.

The jury concludes that there was a gross failure on the part of the nursery to provide appropriate care to Tiya. Inadequate communication between all staff led to gross failure of supervision of Tiya which was a significant contributing factor to her death.

The sensory tray activity containing the jelly cube was not adequately risk assessed, neither was it adequately supervised by staff, and for a period of time there was not sufficient supervision of room 3.

Conclusion of the Jury as to the death

Tiya Chetan Chauhan died as the result of an accident contributed to neglect.

It was clear from the evidence taken during the inquest that the conforming nature of the raw jelly made it particularly difficult to clear from Tiya’s airway once it had formed an obstruction. Small children are at an increased risk of choking due the size of their airway, their incomplete dentition and their tendency to put things in their mouths. The risk of choking from the raw jelly had not been adequately appreciated by the setting, and nor had appropriate supervision been put in place of the sensory activity containing the raw jelly cubes.

(1) That nurseries, other childcare and school settings and even parents may be using raw jelly during play without appreciating the especial risks of choking that a cube of raw jelly presents.

(2) That packets of raw jelly do not contain a warning that cubes of jelly present a choking risk to children.

(3) That raw jelly cubes may be used in play with young children without sufficient supervision.

(4) That LAs and Ofsted learn lessons from this tragic death and ensure appropriate warnings are communicated to the settings overseen by them and training and inspection is organised and implemented as required to mitigate the risk from raw jelly play.