Recently I had the opportunity to act as an expert witness at a coroner’s inquest into the death of a young man who died of anaphylaxis in school. Fortunately, fatal anaphylaxis is extremely rare but tragically when it does happen, there are always lessons to be learnt. It is enormously important to identify these lessons and the appropriate changes which can be made to minimise the risk of something similar happening again. This is very much the role of the coroner and I was really pleased that she was able to really hone in on and highlight some vital issues.
Frustratingly, she had already come across a number of these issues in the past and found herself having to reiterate them because they had not been satisfactorily addressed, despite previous ‘Prevention of Future Death’ notices. In this case, the majority of these lessons related to the way that food allergy was being managed in the school and indeed this was significantly wanting in many regards. As was widely reported in the press around this case, this young man’s EpiPen device was some months out of date, which could have affected how well it worked and there was also some delay in how quickly it was given.
Whilst it can be easy to criticise the school for these issues, I am very much aware from the many stories I hear from my patients, that something similar could very easily happen in any number of schools up and down the country. It is essential that we do our best to try and improve things around this.
My personal view is that we very rapidly need much more consistency in the policies that schools have around managing food allergy. There are some fantastic examples of how this can be done well, with very effective policies that are carefully adhered to and expertly implemented. Allergy UK shared some excellent examples on their website https://www.allergyuk.org/information-and-advice/for-schools/whole-school-allergy-awareness-management to show how to manage food allergies effectively in school via a ‘whole school’ approach. It is not just a case of managing the individual child’s food allergy – there are a number of other factors beyond just catering issues which need to be taken into account, including education for their peers as well as staff around risks, recognising allergic reactions and responding promptly. Of course, just having a policy is not enough – it needs to be robustly implemented to ensure that the appropriate emergency medication is administered in the right place at the right time and that the right people know how to use it quickly and correctly.
One of the key learnings from many of the small number of fatal anaphylaxes that happen, is the importance of not delaying the administration of adrenaline. The important fact that adrenaline devices are completely safe to use still does not seem to be getting through and as a consequence people are nervous about using them in case a reaction is not severe enough. In truth, an adrenaline device given to a completely well child, beyond perhaps causing a headache or some palpitations is absolutetely safe and my advice to patients at risk of anaphylaxis is that if they are not sure whether the reaction is severe enough to warrant using adrenaline, then they should simply use it. Whilst of course it is always important to call for help if there is a serious allergic reaction, I also counsel patients to use their adrenaline device first and then call for help second.
The coroner in the case has issued a series of Prevention of Future Death notices, that have gone out to a wide range of stakeholders and whilst I am in the process of preparing mine on behalf of the British Society for Allergy & Clinical Immunology, I have also written to Damian Hinds – the Minister for Education, together with representatives of Allergy UK and the Anaphylaxis Campaign to ask for him to take action on this issue. We have asked that he works with us to develop a high quality standardised approach to the management of food allergies in school, that can then be disseminated as part of the ‘Supporting Children with Medical Conditions in School’ guidance which is statutory for all schools to follow. This will hopefully be our best chance of ensuring that the advice being given is easily accessible and the best it can be. I look forward to seeing how things progress here.