A boy who threw cheese at a fellow pupil with a dairy allergy causing a fatal reaction did not intend to cause him serious harm but the school should have done more to prevent it, a coroner has said.
Karanbir Singh Cheema, 13, known as Karan, went from being “absolutely fine” to unconscious in less than 10 minutes after the incident at William Perkin Church of England high school in Greenford, west London, on 28 June 2017. Karan, described as “kind, gentle and intelligent”, died 10 days later at Great Ormond Street hospital with his family at his side.
Returning a narrative verdict at St Pancras coroner’s court on Friday, the senior coroner for inner north London, Mary Hassell, said the boy who had thrown the cheese and the one who had passed it to him were oblivious to the potential consequences.
It was a “childish and thoughtless act but was not calculated to cause serious harm”, she said.
However, Hassell laid the blame for two contributory factors in Karan’s death at the door of the school. She said: “Most importantly in terms of the potential to change the outcome, there was a missed opportunity by Karanbir’s school to raise awareness among their pupils of the grave nature of his allergies and the care that needed to be taken to avoid his contact with allergens.”
The coroner also described the school’s healthcare provision for Karan as “inadequate”, citing an “insufficient” care plan, the fact that there was only one Epipen in his medical box – although his mother had said he needed two – and the lack of a robust system for checking medication was in date.
The inquest heard that only one Epipen dose had been given to Karan, which was 11 months out of date. School staff said they had not given him a second Epipen because they thought a 10-minute gap was necessary between doses, had not been told to do so by the ambulance operator and he only had one Epipen in his medical box.
Hassell said: “It is impossible to to say whether the use of adrenaline that was in date or the administration of a second Epipen would have changed the outcome but they would have given Karanbir a better chance of survival.”
A lawyer for Karan’s mother, Rina, said the family was considering taking action against the school in light of concerns “about the part the school played in Karan’s death”.
Another contributory factor cited by Hassell was “the national lack of understanding about the necessity of giving an Epipen immediately there are breathing difficulties”. She added that a second Epipen should be given five minutes after the first or immediately in the event of a deterioration.
The coroner said she would be issuing reports on the prevention of future deaths to nine organisations, including the school, the Department for Education and the Department of Health, in an attempt to guard against similar incidents.
She described Karan’s reaction to an allergen that was not ingested but only ever in contact with his skin as “extraordinarily rare”.
During three days of evidence last week, the court heard from Dr Adam Fox, a consultant paediatrician and leading expert on anaphylaxis, that if skin contact alone had caused Karan’s fatal anaphylaxis, it would be unprecedented.
The boy who flicked the cheese and another boy who passed it to him gave evidence from behind a screen during the hearing. Both aged 13 at the time of the incident, the boys told the inquest they had been unaware Karan had an allergy.
Rina Cheema described Karan as her “best friend” and “the star of the show”. His father, Amerjeet, said he hoped lessons would be learned as a result of the inquest. He said: “Karan’s death has left us with a hole that will never be filled. The sorrow and sadness of losing Karan is so palpable and fresh it seems we will never be able to overcome it.”
Dame Alice Hudson, the executive headteacher of the Twyford Trust, encompassing the school, said: “We are deeply sorry that we could not save Karan. We completely accept the coroner’s findings about the systems we had in place at the time, and regret that they were not enough.”