IT IS HARD TO listen to the evidence being given at this inquest. It is a catalogue of ineptitude, a recounting of bewilderment – and above all it is a story of a lack of care and compassion. How can this happen at a Tower Hamlets school?
It had already been revealed that Nasar’s care plan had been botched by Goddard Edwards, a school nurse who was responsible for the care of pupils with medical needs, in what this man called an “oversight”. The latest batch of evidence concerned how the care plan proved inadequate to deal with the medical emergency.
One piece of information given to the inquest has helped clarify why Nasar said he felt unwell after he had been sent to detention. Evidence was given that a school cook had reported that Nasar had eaten tandoori chicken for lunch – tandoori chicken which contained milk. Milk was one of the seven food items Nasar was severely allergic to.
This raises some questions which the community needs answering. How did a boy who had a severe allergy come to eat a school dinner containing one of the foods he was allergic to? What procedures should have been in place to help him choose his dinner safely? Did those procedures fail (and, if so, why?) or were there no procedures?
Nasar’s allergies (and his asthma) were recorded in his school care plan, but Mr Edwards had used the wrong form – so Nasar’s allergies were recorded as “mild to moderate” rather than “severe”. The care plan should also have contained information about what staff should do if Nasar was taken ill: in particular how to use an epi-pen if Nasar fell into anaphylactic shock as a result of an allergic reaction and how to help him use his inhaler if he had an asthma attack. The inquest heard the detail of what happened and why the care plan was inadequate.
Siobhan Newman, a learning assistant, was on duty in the exclusion room when Nasar started feeling unwell. He said he could not find his inhaler and she went to fetch an inhaler from reception. She was told she needed to give them the name of the pupil who needed the inhaler so she could be given the right one – so she had to go back to the detention room to check the name of the pupil.
Meanwhile, Emily Keith-Young, a school admin assistant who was in reception, received a call and she took Nasar’s first aid kit to the exclusion room. The care plan was in the kit and she read out the allergy care part – but not the action plan part. There were no instructions on how to use the epi-pen in the care plan.
School first aider Cherie Hyde told the inquest that she was in the exclusion room before Ms Keith-Young arrived and Nasar had managed to say to her, “Miss I can’t find my pump.” She explained that she had therefore concentrated on trying to help him use his pump – which is why she had not considered the possibility of Nasar suffering from an allergic reaction and needing his epi-pen. She put Nasar into the recovery position and looked for his pulse while he lay there, struggling to breathe.
Ms Keith-Young and Ms Hyde both said that Nasar was struggling to breathe and they had therefore not been able to administer the inhaler.
During the five minutes between the emergency services being called and them arriving, Nasar could have received emergency assistance from the items in his emergency first aid kit. He was not given emergency assistance. Coroner Ms Mary Hassell kept asking Ms Hyde why none of the emergency equipment had been used.
PE teacher Gemma Anderson was present in the exclusion room. After the emergency services had been called, she stayed on the phone receiving advice on what to do from the call handler. Ms Hyde admitted that the call handler was not told that Nasar had been asking for his inhaler and the Coroner pointed out that if this had been done, the call handler may have been able to advise differently (though no one would have known if the outcome would have been different if this had been done).
The inquest into Nasar’s death continues. In the meantime, we hope no one at LBTH has lost any time in contacting all Tower Hamlets school to make sure that correct policies and procedures are in place to look after our children reliably – and that these include having trained personnel and the correct equipment in the right place, within the right time.
•To read about the earlier evidence given to the inquest, go to: