Child Death

Disputed (AI summary) Bow School is improving medication management systems, ensuring robust monitoring, and supporting staff to provide effective interventions; the school will brief staff on medical policies and procedures (repeated September 2017), place awareness posters throughout the school, annotate menus with allergens (September 2017), raise awareness of medical needs via Anaphylaxis Campaign and PSHE curriculum, and offer first aid training to pupils (Year 9 in July 2017, all pupils next year). The Department of Health will not pursue making generic adrenaline auto-injectors available in public places due to safety concerns raised by the MHRA, but they are amending regulations to allow schools to hold spare auto-injectors without a prescription for emergencies, effective from 1 October 2017, and are developing guidance for school staff on their use. BSACI has produced national guidelines for managing various allergies, promotes written personalized emergency management plans, and has been part of a campaign to allow schools to hold spare adrenaline auto-injectors, with revised regulations coming into effect on 1 October 2017, and is developing a website to support school staff. Compass Wellbeing has undertaken an internal investigation, reinforced accurate record keeping, provided medico-legal training on documentation, reviewed and reran training on their Competency Framework, and is implementing an electronic diary system with reminders for follow-up actions. The London Ambulance Service (LAS) disputes the coroner's concern, stating that the Clinical Hub paramedic did not advise against using the EpiPen and that the call was appropriately managed and the LAS will take no action. Barts Health NHS Trust will implement an action plan, work with partners on the Asthma Friendly Schools Project, promote the Healthy London Partnership Paediatric asthma toolkit, improve knowledge of long-term conditions in childhood, and standardize asthma management across Tower Hamlets in line with London Paediatric Asthma standards. The practice discussed the case as a team, reviewed individual consultations, contacted the pharmacy, and contacted the safeguarding team and hospital respiratory team for learning; the nursing team will now post/email a copy of the asthma action plan to the child’s school health team or give a copy to parents to hand in, starting July 2017; the nursing team will investigate anaphylaxis care plans in secondary care and incorporate them into care plans by September 2017.