Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate allergy action plan communication in school
The earlier warning
Nasar Ahmed · 12 May 2017 · Mary Hassell, Inner North London
“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).”
judiciary.uk/…/nasar-ahmed-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Nasar Ahmed (12 May 2017) · stated 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.”
judiciary.uk/…/2023-0134-Response-from-Department-of-Health-and…
Stated action 2 · response to Nasar Ahmed (12 May 2017) · stated timescale: none stated
“Implementation of the Asthma Friendly Schools Project”
judiciary.uk/…/2023-0134-Response-from-Barts-Health-NHS-Trust-.…
What recurred
- 10 May 2019 · Karanbir Cheema · ME Hassell · Closely related · confidence 0.88 (high)
The clearest link, quoted from both reports:
Earlier · 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).”
Later · 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.”
What happened next
No web check of the stated actions has been published for this chain.