What happened
On Wednesday 28 June 2017 another pupil threw a small piece of cheese at a 13-year-old at a secondary school in west London. The coroner’s report of 10 May 2019 records that he was known to be allergic to cheese, went into anaphylactic shock and died on 9 July 2017.
The BBC’s report of 3 May 2019 adds that the auto-injector kept at the school was eleven months out of date and the only adrenaline given before he arrested. An allergy consultant told the inquest that a fatal reaction from skin contact alone was “unprecedented”.
The outcome
The inquest concluded on 10 May 2019 with a narrative determination; no prosecution of any pupil is recorded. The coroner’s Regulation 28 report went to nine recipients, among them the school, the hospital trust, the ambulance service and the Department for Education.
Most of the twelve matters of concern sit with the school. Pupils’ understanding of his allergies was “patchy”. The care plan and the medical box were never checked against each other, so a plan specifying two injectors did not guarantee two. The two messages the coroner called vital, adrenaline at the first sign of breathing difficulty and a second dose after five minutes, were on neither the box nor the staff training.
Beyond the school, a hospital review was never rebooked and the 999 operator did not suggest a second dose. Nor was this new: the coroner’s reports of May 2017, after another pupil died that November, were still partly outstanding.
What went wrong
Four failures, none of them the throw. The plan and the kit were never reconciled: a care plan specifying two injectors is intent, the box is fact, and nobody set one against the other.
Expiry was nobody’s job. The injector eleven months past its date was the only adrenaline given.
The knowledge sat in the wrong places. The doctors’ plan did not reach the school, and pupils knew the allergy existed but not what it was or what exposure would do.
The response was trained to the wrong first move: first aid did not begin with adrenaline, and the box carried no instruction on its outside.
What it teaches
Allergen safety is a behaviour and supervision question before it is a catering one. The plan was written around the allergic pupil; the hazard came from another child, and no document held for one child controls what another does.
Peer education is a control measure. It reads as pastoral work; the coroner treated it as safety equipment.
Plans and stock rot apart unless somebody audits them together, on a date, with a signature.
Questions for the room
- If a care plan says two auto-injectors, who counts them, and where is the check recorded?
- What would a pupil in your school do in the first minute of a classmate’s reaction, and is that taught?
- Of these twelve matters of concern, which could your school answer “closed” today, with evidence?
Evidence and limits
Confidence: confirmed. The Regulation 28 report, reference 2019-0161, and the BBC’s report of 3 May 2019 were both read live on 7 November 2026.
The pupil is not named at any age, nor are the school or the hospital trust, because either identifies him; the page says a secondary school in west London. The report’s own URL carries his name, so the page cites the Prevention of Future Deaths index and the reference instead.
The report states concerns; it does not find that the school caused the death, and it records expert evidence that a fatal reaction from skin contact alone was unprecedented.
Our physical intervention training treats pupil-on-pupil risk as a supervision and behaviour problem, with the medical response alongside it.
Sources
- Courts and Tribunals Judiciary, 10 May 2019 · Regulation 28 report 2019-0161 · https://www.judiciary.uk/prevention-of-future-death-reports/
- BBC News, 3 May 2019 · https://www.bbc.com/news/uk-england-london-48148697
Reviewed 7 November 2026.