HOW MANY FAMILIES must go through the agony of losing a son before schools learn how to cope with children’s allergies? A third boy with recorded allergies has lost his life because a school dealt with his fish allergy – by feeding him fish fingers.
Nine year old Ismaeel Ashraf died on 3rd March, but the story has only now come out after an inquest into his death concluded. He was a pupil at the Al-Hijrah School in Bordesley Green, Birmingham. The school had a “red book” which listed pupils who had allergies and what they were allergic to. Ismaeel’s name was in the red book, and it said he was allergic to fish (and nuts, dairy products, tuna in brine and kiwi fruit).
A kitchen assistant, Gemma Sheedy, explained at the inquest that pupils with allergies (there were about five of them in the school) used to war badges showing their allergies, but after a while they stopped doing so. The kitchen assistants knew which boys used to wear the badges, so no one bothered to insist that the badges were worn.
The inquest heard that Ismaeel went to the canteen for his lunch on the day he died. Ms Sheedy said she asked the chef if “the allergy boys” could have fish fingers (which, obviously, contained fish). The chef said that Ismaeel could have the fish fingers. She therefore served them to him. She also said that she had never looked at Ismaeel’s entry in the red book until after he had died – when she was shocked to see that he was allergic to fish.
Around an hour after lunchtime, Ismaeel told teachers his tummy was hurting. He was told to walk down to the school’s reception area, with another pupil going with him, and when he got there someone gave him Pirotin. He began having difficulties breathing and asked for his inhaler. He told staff, “I’m going to die” – and seconds later he suffered a cardiac arrest.
Ambulance staff then arrived and administered his Epipen. The time taken for staff to realise Ismaeel was seriously ill, react (wrongly), for him to reach reception and for staff to look for his Epi-Pen meant the Epi-Pen was administered around half an hour after Ismaeel first reported feeling ill. Ismaeel was taken to Heartlands Hospital, where he was pronounced dead.
The school pointed out that a member of staff stayed with Ismaeel in reception. It would have been a great deal more helpful if the staff had observed Ismaeel’s written care plan, which was in the school’s possession. This said that if Ismaeel had an allergic reaction he should not be moved and that his antihistamines and Epi-Pen should be brought to him and the Epi-Pen should be administered immediately.
Three senior doctors gave evidence to the inquest. All of them said that they doubted that the fish fingers had made Ismaeel ill, because severe allergic reactions usually occur within less than 30 minutes – whereas Ismaeel did not report feeling ill until over an hour after his lunch. However, they did think it likely that the delay in using the Epi-Pen had contributed to Ismaeel’s death.
The coroner criticised the school. The jury at the inquest decided that neglect played a part in Ismaeel’s death. Birmingham Coroner Louise Hunt said she would now send a Report to Prevent Future Deaths to all the parties involved in this incident. She warned that the school was still not safe, saying, “Care plans are still not in place for all pupils with health needs, including Ismaeel’s sister who is also a pupil at the school. Not all the care plans which have been drawn up have been given to the catering company responsible for dishing up all meals. Lanyards meant to be worn round the necks of children with food allergies are not being worn properly.”
It was also revealed that Birmingham City Council had produced a report on Ismaeel’s case which included recommendations on actions to stop similar tragedies occurring in the future. However, the report had not been sent to schools. How can this happen?
Ismaeel’s father paid tribute to his son. He told the inquest, “He was a very keen football fan and we would often play football in the park. It was our little way of spending father and son time together. He was very mature for his age. When we went shopping he picked up food that he likes and then the first thing he did was check the ingredients to check if he was allergic to it. It happened just before the Easter holidays. He had so many plans with me and his mum about what he wanted to do in his break.”
The Al-Hijrah School was inspected by Ofsted in December 2015. It was found to “require improvement” in all areas. It was inspected again three weeks after Ismaeel died – and Ofsted reported that its performance was significantly worse. It received two “receiving improvements” and four “inadequates”. Too little, too late, Ofsted reported that “Procedures to support pupils who have medical needs are not clear. Staff are not sufficiently aware of what to do in medical emergencies.”
This story on its own would be shocking enough, but it is made all the worse by the fact that Karam Cheema died in Ealing in June and Nasar Ahmed died in Bow School, Tower Hamlets, last November in strikingly similar circumstances. That’s three schoolboys dead in schools which had care plans which were not followed and medication which was not administered. Three coroners have made recommendations to avoid future deaths in similar circumstances. Why is no one listening?