Source · Prevention of Future Deaths

Khadija Ahmed

Ref: 2021-0410 Date: 2 Dec 2021 Coroner: Mary Hassell Area: Inner North London Responses identified: 1 / 1 View PDF

School staff, including the teaching assistant, lacked cardiopulmonary resuscitation (CPR) training, resulting in no CPR being attempted during a child's cardiac arrest.

Date 2 Dec 2021

56-day deadline 27 Jan 2022 est.

Responses identified 1 of 1

Other related deaths

Coroner's concerns

AI summary

School staff, including the teaching assistant, lacked cardiopulmonary resuscitation (CPR) training, resulting in no CPR being attempted during a child's cardiac arrest.

View full coroner's concerns

I heard that the teaching assistant looking after Khadija was not trained by the school in cardiopulmonary resuscitation and that, when Khadija became unresponsive, CPR was not attempted by any staff member. It is highly unlikely that CPR would have changed the outcome for Khadija. The cause of her cardiac arrest was an airway compromised by mucous plugging, that even a highly trained paramedic crew was unable to clear. However, CPR might make a difference for another child, or even for a staff member.

To put the lack of CPR in context, the care that Khadija received from the school before the arrest seemed to be of a very high standard, even drawing comment from a paediatric intensive care consultant giving evidence at inquest. He told me that many nurses at Great Ormond Street Hospital would not have been able to administer the treatment that Khadija’s teaching assistant did on 1 July 2021. She was quick to recognise that something was wrong and quick to act appropriately.

However, it seems to me that the school would benefit from consideration being given to frequent CPR training.

Responses

1 respondent

Swiss Cottage School Education

11 Jan 2022 PDF

Action Taken

Swiss Cottage School has organised Basic Life Support with CPR training for 70 members of staff, timetabled to every class across the school, delivered on 12th and 14th January 2022. (AI summary)

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Dear Senior Coroner ME Hassell,

Thank you for providing us with the Regulation 28: Prevention of Future Deaths Report for AKA, dated 2nd December 2021 and received via email on 7th December 2021. Within the report you outline a recommendation for the school to organise regular CPR training and requested an update by 31.1.22.

I am writing to confirm that the school is completing this recommendation on 12th January, 14th January, and within our annual training cycle.

-Basic Life Support with CPR training is organised for 70 members of staff.
-The 70 staff are timetabled to every class across our school.
-The training is taking place on 12th January and 14th January 2022.
-The provider of the training is:

Resuscitation Officer Resuscitation Services Level 4 Nurses Home Great Ormond Street London WC1N 3JH

This is alongside the safeguarding and health training that is on an annual cycle.

Thank you for the report and please let us know if you require any further information.

Kind Regards,

Principal

CC: , Head of SEN and Inclusive Intervention Services for Camden Local Authority

Report sections

Investigation and inquest

On 9 July 2021, one of my assistant coroners, Richard Brittain, commenced an investigation into the death of Khadija Ahmed, aged 6 years. The investigation concluded at the end of the inquest yesterday. I made a determination at inquest that death arose from natural causes. The medical cause of death I recorded as follows. 1a hypoxic brain injury 1b out of hospital cardiac arrest secondary to mucous plugging 1c spinal muscular atrophy type 1

Circumstances of the death

Khadija suffered a cardiac arrest whilst at school on 1 July 2021. This caused a hypoxic brain injury from which she died a week later.

Copies sent to

, teaching assistant, Swiss Cottage SchoolMedical Director, Royal Free HospitalChief Executive, London Ambulance ServiceMedical Director, Great Ormond Street Hospital for Children

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Shared signals

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Report details

Reference: 2021-0410
Date of report: 2 December 2021
Coroner: Mary Hassell
Coroner area: Inner North London

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 27 Jan 2022 (estimated).

Sent to

Swiss Cottage Special School

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.