Source · Prevention of Future Deaths

Karanbir Cheema

Ref: 2019-0161 Date: 10 May 2019 Coroner: ME Hassell Area: London Inner (North) Responses identified: 2 / 8 View PDF

The report details issues at the deceased's school, including a patchy understanding of allergies, unchecked care plans and medical boxes, out-of-date medication, non-standardised allergy action plans, and a failure to send allergy action plans to the school.

Date 10 May 2019

56-day deadline 23 Sep 2019 est.

Responses identified 2 of 8

Child Death (from 2015)

Coroner's concerns

AI summary

View full coroner's concerns

I am aware that some changes have been made since Karanbir’s death and therefore do not need to be re-iterated now, but others remain outstanding. Some issues I raised before Karanbir’s death, in PFD reports I made in May 2017 following the death of Nasar Ahmed on 14 November 2016.

1. The pupils at Karanbir’s school had a patchy understanding of his allergies, what they were and the consequences of exposure to allergens. Targeted education about this would improve safety.

2. Karanbir’s school care plan and medical box were not checked or audited to ensure, for example, that if his care plan stipulated two EpiPens® (adrenaline auto-injectors), the box contained two EpiPens.

3. Karanbir’s EpiPen was out of date. There must be systems in place to ensure that medication in schools is in date.

4. Allergy action plans are not standardised across hospitals and schools, so messages are not as clearly delivered as they could be. This is vital particularly when they may be read for the first time in a desperate situation where panic has set in.

5. The allergy action plan drafted by Karanbir’s doctors at Ealing Hospital did not find its way to his school. There is no standardised approach to this, for example always sending a copy to the school designated safeguarding lead, as well as giving parents/carers a copy for themselves and a copy for the school in case the posted version does not arrive.
6. Karanbir’s treating doctors wanted him to re-attend for asthma and allergy review four months after his last consultation. An appointment was made but cancelled by the hospital. By the time of his death four months later he had still not been seen again. There needed to be recognition of the time critical nature of this appointment. It needed to be re-booked without delay.

7. Karanbir had one EpiPen at home, one at school and one at his father’s home. There is clearly a need for medical teams to emphasise that two EpiPens must be available at all times.

8. There appears to be a lack of awareness nationally of the simple but vital messages that:

- if a person with an allergy has been exposed to an allergen and develops any respiratory compromise, so any breathing difficulty at all, then adrenaline (via EpiPen or other) should be administered immediately, before any asthma pump and even before calling for help;

- if there is a deterioration after giving one EpiPen, then another should be administered immediately, or in any event after five minutes if there is no improvement.

9. The EpiPen box does not contain these instructions on the outside.

10. These instructions were not communicated effectively as part of the school staff’s first aid and EpiPen training.

11. The London Ambulance Service 999 operator did not at any time suggest that a second EpiPen be given, because this is not contained within the algorithm. That could be remedied internationally.

12. The allergy specialist who gave evidence was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.

This was the view of the respiratory physician who gave evidence in May 2017 and about which I wrote then to the Chief Medical Officer for England. Is this worthy of reconsideration?

Responses

2 respondents

Response Ambulance Service NHS Trust NHS / Health Body

1 Jul 2019 PDF

Action Planned

The London Ambulance Service raised the PFD regarding EpiPen usage with the UK Clinical Focus Group for IAED-MPDS and with the Executive Director of MPDS and awaits their conclusion. The Chief Medical Officer has shared the PFD with the Chair for The National Ambulance Service Medical Directors for their consideration. (AI summary)

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Dear Ms Hassell, Regulation 28: Prevention of Future Deaths Report- Karanbir Cheema Thank you for your Regulation 28 Prevention of Future Deaths (PFD) report dated 10 May 2019_ The Trust welcomes your recommendation for changes to prevent future deaths and would like to take the opportunity at the outset of my letter to offer my sincere condolences to Karanbir Cheema's family: The matter of concern vou raised at the inquest is as follows: The London Ambulance Service 999 operator did not at any time suggest that a second EpiPen be given, because this is not contained within the algorithm: That could be remedied internationally: In the United Kingdom there are two 999 call triage systems; NHS Pathways and Medical Dispatch Priority System (MPDS): The London Ambulance Service NHS Trust (LAS) processes 999 calls via MPDS which is devised by the International Academy of Emergency Dispatch (IAED): As you are aware, under the terms of the licence to use MPDS the LAS as a licenced user does not have jurisdiction to make changes to the call taking protocols unilaterally ad must submit requests for change to the Standards Committee of the IAED: am advised by our Chief Medical Officer that this PFD was raised at the UK Clinical Focus Group for IAED-MPDS on 22 May 2019 and has also been raised with the Executive Director of MPDS} The group welcomed this recommendation and we await their conclusion/outcome: Our Chief Medical Officer has taken the opportunity to share this PFD with he Chair for The National Ambulance Service Medical Directors (NASMED) for their consideration who will raise it with the Association of Ambulance Chief Executives (AACE): As the Trust is also a NHS 111 provider for integrated urgent care, this PFD has also been raised with the Chair of NHS Pathways National Clinical Governance Group and the NHS Pathways Deputy Clinical Director. hhas confirmed that NHS Pathways advises to give another dose if there is no improvement after the first dose and states that "If the individual's condition does not improve adrenaline should be repeated if available after 10-15 minutes, according to the manufacturer's instructions"_ Mary

hope this reply is helpful in explaining the actions taken to address the matter of concern:

London North West University Healthcare NHS Trust NHS / Health Body

PDF

Action Taken

The Trust will review allergy action plans and injection techniques with children and carers in the clinic. They have added the additional process of posting or emailing each allergy plan to the school in question and advised the relevant department that before a clinic list is cancelled, the clinician is to review for time-critical appointments. Changes have been made so two adrenaline auto-injectors are kept with the child and two at school. (AI summary)

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Dear Ms Hassell RE: Recommendations following the inquest of Karanbir Singh Cheema concluded on 10
2019. write further to the conclusion into the inquest of Karanbir Singh Cheema wherein you raised 12 matters of concerns against nine organisations_ Four of those concerns relate to the London Northwest University Healthcare NHS Trust namely: 1_ (Point 4 of matters of concern listed in the Prevention of Future Death Report) Allergy action plans are not standardized across hospitals and schools, so messages are not as clearly delivered as they could be_ This is vital particularly when may be read for the first time in a desperate situation where has set in: 2 (Point 5 of matters of concerns listed in the Prevention of Future Death Report) The allergy action plan drafted by Karanbir's doctors at Ealing Hospital did not find its way to his school_ There is no standardized approach to this, for example always sending a copy to the school designated safeguarding lead_ as well as giving parents carers a copy for themselves and a copy for the school in case the posted version does not arrive. 3 (Point 6 of matters of concerns listed in the Prevention of Future Death Report) Karanbir's treating doctors wanted him to re-attend for asthma and review four months after his last consultation: An appointment was made but cancelled by the hospital. By the time of his death four months later he had still not been seen again. There needed to be recognition of the time critical nature of this appointment: It needed to be re-booked without delay: (Point 7 of matters of concerns listed in the Prevention of Future Death Report) Karanbir had one Epipen at home, one at school and one at his father's home. There is clearly a need for medical teams to emphasise that two EpiPens must be available at all times_ Trust Headquarters: www Inwhnhsuk Northwick Park Hospital, Watford Road, Harrow, HAI 3UJ

T+44 (0120 8864 3232 or Iike US on Facebook at london North West Healthcare May they panic allergy

You gave the Trust six days to consider this issue and write to you setting out how the Trust proposes to address your concerns. The Trust has taken your concerns very seriously and has made the following changes:
1. Standardized allergy care plans Following this case, the paediatric allergy leads from Ealing and Northwick Park Hospital advise that they use and advocate the BSACI Allergy Action Plan for any child with an allergy which is printed in colour from clinic and 2 copies are given to parents (one to be kept at home and one for them to share with the school nurse or welfare officer of the school) , and this is shared with the GP and a copy is left in the clinical records. This information has been presented to the Paediatric team in the Departmental Clinical Governance meeting on 26 June 2019. Education and training of the use and administration of cetirizine and adrenaline auto-injector is given to the child at the same time as the action plan from clinic as point of care after identification of the allergy: To ensure this we will go through the allergy action plans and injection technique with the child (if age appropriate) and the carers in clinic always: 2 Sharing of the allergy care plan with the school have been advised by the clinicians that the usual practice is training the parent (and child) first and informing them to tell the school of the child's allergy and avoidance of the precipitant: Following Karanbir's inquest; the Trust has added the additional process of posting or emailing each allergy plan to the school in question.
3. Re-booking cancelled clinics The relevant department has been advised that before a clinic list is cancelled (when there are patients already in the list) , the clinician is given the Iist of patients of the clinic who then looks through to see if any of the appointments are "time critical" (as it was in Karanbirs case) and then instructs the secretary or access centre to send out the appropriate alternate date for the next appointment.
4. Availability of two adrenaline auto-injectors The Trust has made changes in that there will be two adrenaline auto-injectors to be kept with the child at all times and two to be kept at the school, so GPs will be asked to prescribe 4 adrenaline auto-injectors The GP will be asked to prescribe 3 adrenaline auto-injectors if it is known that the school has generic adrenaline auto-injector for use for any child

Report sections

Investigation and inquest

On 12 July 2017 I commenced an investigation into the death of Karanbir Cheema, aged 13 years. The investigation concluded at the end of the inquest today. I made a narrative determination at inquest, which I attach to this letter.

Circumstances of the death

Karanbir was attended William Perkin High School. On Wednesday, 28 June 2017, another pupil threw a small piece of cheese at him. He was known to be allergic to cheese and he went into anaphylactic shock. His medical cause of death was:

1a post cardiac arrest syndrome 1b anaphylactic shock 1c multiple food allergies bronchial asthma

Copies sent to

Care Quality Commission for EnglandMedicines and Healthcare Products Regulatory AgencyAssociation of Ambulance Chief Executives (AACE)National Ambulance Service Medical Directors (NASMeD)Health and Safety ExecutiveSafeguarding Children BoardChild Death Overview Panel, Karanbir’s mumKaranbir’s dad

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2019-0161
Date of report: 10 May 2019
Coroner: ME Hassell
Coroner area: London Inner (North)

Responses identified

Responses identified 2 of 8

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 23 Sep 2019 (estimated).

Sent to

British Society for Allergy and Clinical Immunology

Department for Education

Department of Health and Social Care

London Ambulance Service

London North West University Healthcare NHS Trust

Mylan Pharmaceuticals

Royal College of Paediatrics and Child Health

William Perkin High School

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.