A popular schoolboy with a dairy allergy died from an “extraordinary reaction” when a piece of cheese was flicked at his neck by another pupil in a “childish and thoughtless act,” an inquest heard.
Karanbir Singh Cheema, known as Karan, went into anaphylactic shock when the cheese half the size of a ‘Post-it’ note landed on his skin at his school in Greenford, west London, just before noon on June 28, 2017.
Today senior coroner Mary Hassell recorded a narrative conclusion into his death said the main factor was his severe allergy.
Ms Hassell added the pupil who flicked the cheese did not mean any harm and “all of the evidence point to the cheese being responsible for Karanbir’s death.”
But she called for schools to better educate pupils to the dangers of allergies and for care plans for children with allergies to be beefed up.
Karan, 13, was severely allergic to wheat, gluten, all dairy products, eggs and nuts and he was also asthmatic and suffered from atopic eczema.
On the day one of Karan’s school mates gave another boy the piece of cheese and allegedly said “Karan’s allergic to cheese,” but he denied this.
The other boy then threw the cheese at Karan who went into anaphylactic shock just after 11.30am at William Perkin Church of England High School.
It took just under ten minutes for Karan to go from “absolutely fine” to unconscious.
Unknowingly, staff at the school administered an epipen that was an entire year out-of-date because of a spreadsheet error but they told the inquest at St Pancras Coroners’ Court they would not have used another pupil’s for fear of a “domino effect”.
Karan, who was still unconscious when paramedics arrived at 11.49am, was taken to Northwick Park Hospital in Harrow and then transferred to Great Ormond Street Hospital (GOSH) in central London.
But he never regained consciousness and died ten days later on July 9 with his family by his side.
Consultant pathologist Dr Liina Palm, of GOSH, said Karan’s cause of death was post cardiac arrest syndrome which could have been caused by a number of things including cardiac arrest and anaphylaxis resulting from allergies.
An allergy expert told the inquest said he had never seen another case of a patient dying just through skin contact with an allergen and described Karan’s death as “unprecedented” in medical circles.
Giving her conclusion, Ms Hassell said: “In terms of involvement, I don’t think (the pupil who gave the cheese) had anything to with anything.
“He was eating his cheese baguette and a pupil asked him for some and he went on his way – he simply had no involvement.
“In relation to (the pupil who threw the cheese) I don’t think that he thought ‘Karanbir’s got an allergy, I’m going to hurt him’, I don’t think he thought anything.
“This was a thoughtless act, he simply wasn’t thinking.”
Describing the moments before Karan fell unconscious, the coroner said: “He pulled his shirt off, screamed and flung himself around the room in panic.
“He could not breathe.”
She added: “Whether the cheese went down Kararbir’s throat, it seems to me that the evidence points toward the cheese going down his neck, not his throat.
“He suffered an extraordinary reaction … and it must be difficult to believe because it was so severe.
“All of the evidence point to the cheese being responsible for Karanbir’s death.”
She said Karan “understood his allergies and had a mature approach to avoiding allergens” while the boy who threw the “2cm by 2cm” piece of cheese was “childish and thoughtless”.
The coroner said: “This was a childish and thoughtless act, but was not calculated to cause serious harm.
“Karanbir died because he had an allergic reaction to cheese that was thrown at him by another pupil.
“While the allergies from which he suffered are relatively common, his fatal reaction to an allergen that was no ingested but was only ever in contact with his skin is extraordinarily rare.”
But Ms Hassell added there were “a number” of contributing factors that affected the tragic outcome.
Listing his many allergies, she said he also had “poorly controlled asthma and eczema”.
She said the allergy action plan drafted by Karan’s doctors never made it to his school and the school “did not have an effective system for educating its pupils in the dangers of allergies”.
The coroner criticised the school healthcare provision for Karan adding: “The care plan had never been considered by the school and it contained insufficient detail and instruction.
“Though Karanbir’s mother had clearly recorded that he needed two epipens, nobody at the school checked to see that there were two epipens in his medical box.
“There was a system for checking that pupil medication was in date, but it was not robust and it was not followed properly.”
She said it was “impossible” to know whether the outcome would have been different if the epipen was in date and highlighted a “national lack of understanding” of the necessity of administering epipens immediately.
She said: “It is not possible 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.”
The coroner said she would be sending out a prevention of future deaths report to the school, the LAS, the manufacturer of the epipen, the British allergy association, the Royal College of Paediatrics and the Chief Medical Officer.
It will include a request for standardised allergy action plans, more of a national awareness of allergies and epipens.