Nasar Ahmed

1. 1. lack of public access to adrenaline auto-injectors

   “generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces”

2. 2. delayed or omitted adrenaline administration in anaphylaxis

   “if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately”

3. 3. inappropriate emergency medication device

   “The asthma pump in [the deceased]'s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him.”

4. 4. inaccurate care plan leading to inadequate emergency instructions

   “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)”

5. 5. lack of trained staff to access emergency care plans

   “Not everyone involved in trying to help [the deceased] was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan”

6. 6. inadequate medication verification by non-clinical staff

   “the school nurse (employed by Compass Wellbeing) conducted a review of [the deceased]'s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist”

Linked reports