Coroner slams school where boy died from allergic reaction

Ismaeel Ashraf had been served the meal of fish fingers and chips from the canteen

A coroner has criticised a Birmingham school where a nine-year-old boy died from a severe allergic reaction to something he ate.  

Ismaeel Ashraf had been served the meal of fish fingers and chips from the school canteen at the Al-Hijrah School in Bordesley Green, Birmingham.

An hour later he told teachers that his stomach was hurting, and paramedics were called – but it has since emerged that he was not given an EpiPen to stop the reaction by school staff.

He was pronounced dead at the city’s Heartlands Hospital after the suspected anaphylactic shock on March 3.

The controversial school has been monitored since he died there – with books condoning domestic violence and forced sex found in its library.  

Speaking after the jury returned their conclusion that neglect played a part in the schoolboy’s death, Birmingham coroner Louise Hunt said she would now be writing a Report to Prevent Future Deaths and sending it to all the parties involved in the tragedy.

She said: ‘Care plans are still not in place for all pupils with health needs, including Ismaeel’s sister who is also a pupil at the school.

‘Not all the care plans which have been drawn up have been given to the catering company responsible for dishing up all meals.

‘Lanyards meant to be worn round the necks of children with food allergies are not being worn properly.’

Tehseen Ashraf, father of Ismaeel

Ismaeel Ashraf's uncle

Tehseen Ashraf (left), father of Ismaeel, and the boy’s uncle (right) are pictured outside the inquest at Birmingham Coroner’s Court on Monday

The report commissioned by Birmingham City Council immediately after the death, outlining recommendations to prevent future tragedies, had still not been given to the school five months since Ismaeel’s death.

The jury inquest in Birmingham heard how the school had a red book which stated Ismaeel’s dietary requirements including fish as an allergy.

But kitchen assistant Gemma Sheedy asked the chef if Ismaeel could have the fish fingers, containing pollock, and was told he could.

The schoolboy was actually allergic to kiwi fruit, dairy products, nuts and tuna in brine – but fish was added to the list in the school’s book. The court heard he had fish and chips every week at the school and never had any reaction.

Ms Sheedy said: ‘About five pupils wore badges showing their allergies, one of them was Ishmael but over time the pupils stopped wearing their badges but we already knew what they were.

‘There’s a red book which has people’s allergies in by the counter. But I’ve never looked at Ishmaeel’s. I asked the chef if the allergy boys could have the fish fingers.

‘I was told they could. I was leaving school when told by a colleague Ismaeel had an allergic reaction to fish.

‘When we looked in the book later we were shocked to see Ismaeel was allergic to fish.’

Speaking after the jury returned their conclusion that neglect played a part in the schoolboy's death, Birmingham coroner Louise Hunt (pictured) said she would now be writing a Report to Prevent Future Deaths

Paramedics who tried to help Ismeeal are pictured leaving court

Speaking after the jury returned their conclusion that neglect played a part in the schoolboy’s death, Birmingham coroner Louise Hunt (left) said she would now be writing a Report to Prevent Future Deaths. Paramedics who tried to help Ismeeal are pictured leaving court, right

He had eaten the meal at 12.30pm but the alarm was raised at 1.45pm when he complained to teachers that he was feeling unwell.

Seconds before he suffered a cardiac arrest in reception, the youngster told school staff: ‘I’m going to die.’

Mrs Hunt said: ‘He was sent to the school’s reception and was given Pirotin to treat his allergic reaction at around 2pm.

‘He asked for his inhaler because he had difficulties with his breathing. He was with a member of staff who stayed with him until the ambulance arrived.

‘Ambulance staff then arrived and gave him his EpiPen.’

The school has been monitored since Ismaeel died there and books condoning domestic violence and forced sex were found in its library

The school has been monitored since Ismaeel died there and books condoning domestic violence and forced sex were found in its library

Ismaeel’s care plan stated that he had to remain where he was when a reaction occurred, that he should not be moved and that his antihistamines and Epi-Pen should be brought to him. He must be given a shot of adrenaline as soon as possible.

But the inquest heard how school staff made him walk to reception accompanied only by another pupil, not an adult, where he was given antihistamines.

There was also a delay of around half an hour between him falling ill and receiving his Epi-Pen because teachers ‘didn’t connect the dots’ and realise he was seriously ill. They were also unable to find his Epi-Pen straight away. 

Three senior doctors said the delay in administering the adrenaline possibly contributed to his death. But they said the fish fingers Ismaeel had for lunch in the school canteen were not to blame because it was an hour and 15 minutes after eating them that he fell ill. Most serious reactions occur within less than 30 minutes, the inquest heard.

Ismaeel’s father Tehseen, 38, whose three other children still attend the school, paid tribute to his son at the hearing.

He said: ‘He was a very keen football fan and we would often play football in the park. It was our little way of spending father and son time together.

‘He was very mature for his age, when we went shopping he picked up food that he likes and then the first thing he did was check the ingredients to check if he was allergic to it.

‘It happened just before the Easter holidays. He had so many plans with me and his mum about what he wanted to do in his break.’

When asked if the school had EpiPens, he replied: ‘Yes’.

Ofsted inspectors told of staff who did not know what to do in medical emergencies and gave the school the lowest ranking possible

Ofsted inspectors told of staff who did not know what to do in medical emergencies and gave the school the lowest ranking possible

The school, which is in special measures, has been monitored since Ismaeel died there – and books condoning domestic violence and forced sex were found in its library.

Now it will be taken over by the state with an interim board appointed to oversee that multiple problems identified in a damning Ofsted report are addressed.

The education watchdog issued a highly critical report earlier this year which listed bullying, weak teaching, a chaotic playground and pupils who were unsafe.

Inspectors also told of staff who did not know what to do in medical emergencies and gave the school the lowest ranking possible. 

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