What happened
The pupil was nine, born with univentricular cyanotic congenital heart disease with pulmonary hypertension. On medical advice, and with his mother’s agreement, he joined in and sat out when tired.
On 23 October 2014, at a school disco, he became fatigued. A teacher found him crying, breathless and distressed, took him to the office at 4.30pm and telephoned his mother. He seemed to improve; the teacher left him with two administrative staff, one a permanent first aider, one junior, temporary and not first-aid trained.
At 4.47pm he deteriorated and became “somewhat absent”. The junior member thought he was having a seizure and asked whether to call an ambulance. The first aider did not think so and said no. He had never had a seizure.
His mother arrived at 4.50pm; an ambulance was called at 4.54pm and came at 5.03pm. He arrested on site at 5.14pm and died that evening.
The outcome
The inquest concluded on 24 April 2015 before the senior coroner for inner north London. She determined natural causes: hypoxia following a generalised seizure, in congenital heart disease. No prosecution followed. Whether earlier intervention would have changed the outcome, she recorded, is unclear.
Her Regulation 28 report of 29 April 2015 went to the head teacher with two concerns. Staff knew to call an ambulance in an emergency; the care plan was not wholly clear. It called breathlessness an emergency, though that was by then part of his condition, and did not say that extreme breathlessness with low oxygen saturation was different. Second, the notice some schools display with a photograph and instructions: his was in the medical room only, and was down for a move of premises.
The school’s response says care plans were reviewed and unclear ones now go to the school nurse or consultant.
What went wrong
Neither gap changed the outcome here, she said; either might for another child.
The word did the damage. Calling breathlessness an emergency tells a first aider nothing when breathlessness is the baseline. The plan needed thresholds: what worse than usual looks like, and what to do without asking.
The right reading came from the one without first-aid training, a temporary administrator who had cared for a child with epilepsy. She saw the absent look, asked for an ambulance, and was overruled.
What it teaches
A care plan is written for whoever finds the child, not the clinician who drafted it. The emergency section needs thresholds a non-clinician can see, and the notice needs to be where the people are.
Escalation should not run on seniority. A doubt was voiced and answered, and the answer closed the question. A rule that sends the doubt to the ambulance unless someone can say why not would have survived this mistake.
Questions for the room
- Read a care plan’s emergency section the way a supply teacher will. Could you act?
- If a first aider disagrees with a colleague who suspects a seizure, who overrules whom, and where is it written?
- Where is your highest-risk pupils’ information at 4.47pm, and who can see it?
Evidence and limits
Confidence: confirmed. The Regulation 28 report of 29 April 2015 and the school’s response were fetched live on 7 November 2026; the timeline is the coroner’s; the response, read by OCR, is undated. The Evening Standard, 14 November 2014, reports the family’s account that staff asked the mother about 999 when she arrived; the call came four minutes later. This entry follows the coroner.
No child or member of staff is named, and the school only by phase and borough: his death was reported with his name and photograph. The determination was natural causes, with no finding of neglect.
Our physical intervention training for education teams treats decision-making under pressure as part of the training.
Sources
- Courts and Tribunals Judiciary, 29 April 2015, report 2015-0168 with the school’s response · https://www.judiciary.uk/prevention-of-future-death-reports/
- London Evening Standard, 14 November 2014 · https://www.standard.co.uk/news/london/my-son-would-be-alive-if-school-had-dialled-999-when-he-fell-ill-9860528.html
Reviewed 7 November 2026.