What happened
On 10 November 2016 a Year 9 pupil at a secondary school in east London ate a lunch that set off an allergic reaction. In the internal exclusion room, where pupils are sent for isolation, he complained of breathing problems and collapsed at 2.21pm.
The deputy head who placed him there did not know about his allergies or care plan, the coroner’s report records. A learning assistant with no first aid training supervised the room; she would not have thought to look for it.
The school kept two adrenaline auto-injectors. Staff saw one, considered using it, and did not. A paramedic reached by phone, unable to see him, advised against it, it seems because the classic signs were not obvious. He died on 14 November 2016.
The outcome
An inquest concluded on 12 May 2017 with a narrative determination before Mary Hassell, Senior Coroner for Inner North London. The cause was hypoxic ischaemic brain injury after cardiac arrest, from status asthmaticus, from anaphylaxis.
Per the Guardian’s report of that day, she said that had the injection been given promptly there was “a possibility but not a probability” the outcome would have changed.
She sent five reports to prevent future deaths: to the Chief Medical Officer (should generic auto-injectors be as available as defibrillators?), the ambulance service, the hospital and GP, the school, and the school nurse’s employer.
What went wrong
The care plan in his medication box was wrong: the school nurse had used the “mild to moderate” action plan rather than the “severe with asthma” version, so the box held an injection with no instruction on when to use it.
Nobody in the room had read it: staff were “encouraged” to read care plans but often did not unless there was an excursion; the room’s supervisor had not. Policy required the headteacher’s assistant to be rung for an ambulance, which the coroner called “guaranteed to add delay”. It was not followed.
What it teaches
Placement was not the finding. The coroner said knowing the care plan would not have changed the decision to put him there; the lack of familiarity cost time. Isolation did not cause this death. It decided who was standing there.
Who is in the room decides the first minute. Isolation rooms are staffed by whoever is free. An adult with no first aid training and no briefing on the children there leaves the room without competence.
Encouragement is not a control. A plan staff are “encouraged” to read gets read before trips, not on a Tuesday.
Questions for the room
- Who supervises your internal exclusion room, what first aid training do they hold, and who in it has a medical plan?
- Does your most allergic pupil’s plan say when to use an auto-injector, and is the room’s copy current?
- If a pupil in an isolation room stops breathing, what does your call script tell staff to do?
Evidence and limits
Confidence: confirmed. The Regulation 28 report (ref 2023-0134, 12 May 2017) and the Guardian’s report of that day were read live on 7 November 2026.
The record calls the auto-injector question the coroner’s only matter of concern; the report carries five, one about the exclusion room. This entry follows the report.
He is not named at any age, so neither is the school. Mary Hassell is named, as an adult with a published determination; no member of staff is. Both documents sit at addresses containing his name, so they are cited by publisher and date. What the school changed is not recorded.
Our positive handling training for schools treats the isolation room as a care setting, with the briefing that travels into it.
Sources
- Courts and Tribunals Judiciary · 12 May 2017 · report 2023-0134 · https://www.judiciary.uk/prevention-of-future-death-reports/
- The Guardian · 12 May 2017 · “Mother of boy who died from allergic reaction to dinner criticises school”
Reviewed 7 November 2026.