Inadequate allergy action plan communication in school
Department of Health and Social Care received 2 coroners' reports about this hazard between 12 May 2017 and 10 May 2019.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The school nurse had updated [the deceased]'s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma).”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“I am hopeful that work underway to change the law to allow schools to hold spare auto-injectors without a named individual prescription, for use as emergency back- up to treat anaphylaxis in children registered by the school as being in receipt of a medical prescription for an auto-injector, will tackle some of the challenges which staff faced in this sad case, and which were set out in your determination.”
Stated timescale: 1 October 2017
“Implementation of the Asthma Friendly Schools Project”
- 2 years laterClosely relatedConfidence 0.88 · higha different coroner
“The allergy action plan drafted by [the deceased]'s doctors at Ealing Hospital did not find its way to his school.”
Original on judiciary.uk ↗ Repeated from the earlier report:allergyactionplandeceased'sschool
Department of Health and Social Care responded.Response (PDF) ↗Response (PDF) ↗
- All reports to Department of Health and Social Care
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2017 → 2019Karanbir Cheema2 years after Nasar Ahmed · different coronerClosely relatedConfidence 0.88 · high
Closely relatedConfidence 0.88 · highBoth reports highlight problems with the allergy action plan not being correctly applied or communicated in the school setting, leading to inadequate emergency response.
Nasar Ahmed · 12 May 2017
“The school nurse had updated [the deceased]'s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma).”
Original on judiciary.uk ↗ Karanbir Cheema · 10 May 2019
“The allergy action plan drafted by [the deceased]'s doctors at Ealing Hospital did not find its way to his school.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We have produced a number of national guidelines using a process accredited by N JCE (National Institute of Care Excellence) and these include the following: I. BSACI Guidelines for the Management or Egg Allergy (20 I0 ) 2. BSACI Guidelines for Diagnosis and Management ofCows Milk Allergy (2014) 3. BSACI Guidelines on Adrenaline Auto-injectors (2016) 4. BSACI Guidelines on the Diagnosis and Management of ul Allergy (2017)”
Stated action · timescale: 1 October 2017
“I am hopeful that work underway to change the law to allow schools to hold spare auto-injectors without a named individual prescription, for use as emergency back- up to treat anaphylaxis in children registered by the school as being in receipt of a medical prescription for an auto-injector, will tackle some of the challenges which staff faced in this sad case, and which were set out in your determination.”
Stated action
“Implementation of the Asthma Friendly Schools Project”
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Department of Health and Social Care at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2017 → 2019 | 0.75 | 0.32 | Closely related · 0.88 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Department of Health and Social Care
This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.