Karanbir Cheema
10 May 2019 · Coroner ME Hassell · London Inner (North)
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. patchy understanding of allergies
“The pupils at [the deceased]'s school had a patchy understanding of his allergies, what they were and the consequences of exposure to allergens”
2. incomplete medical box contents
“[the deceased]'s school care plan and medical box were not checked or audited to ensure, for example, that if his care plan stipulated two EpiPens® (adrenaline auto-injectors), the box contained two EpiPens”
3. out of date medication
“[the deceased]'s EpiPen was out of date”
4. non-standardised allergy action plans
“Allergy action plans are not standardised across hospitals and schools, so messages are not as clearly delivered as they could be”
5. failure to deliver allergy action plan
“The allergy action plan drafted by [the deceased]'s doctors at Ealing Hospital did not find its way to his school”
Linked reports
Closely relatedConfidence 0.88 · high
Earlier report
“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).”
This report
“The allergy action plan drafted by [the deceased]'s doctors at Ealing Hospital did not find its way to his school.”
Raised again laterHannah Jacobs: Prevention of Future Deaths Report (1)20 Aug 2024 · 5 years 3 months later
Closely relatedConfidence 0.80 · moderate
This report
“Allergy action plans are not standardised across hospitals and schools, so messages are not as clearly delivered as they could be.”
Later report
“The evidence at the inquest referred to allergy action plans discussed in the healthcare settings and given to parents and patients. [the deceased] displayed what appeared to be excessive salivation at the dentist”
Responses
2019-0161-Response-Ambulance-Service-NHS-Trust.pdf ↗· London Ambulance Service
2019-0161-Response-by-London-North-West-University-Healthcare-NHS-Trust.pdf ↗· London North West University Healthcare NHS Trust